Same-day appointments may be available so please call our office if you want an appointment today. 

 

Please be aware that you are submitting a request only. A representative from our office will contact you within 24 to 48 business hours to confirm a date and time. If this is a medical emergency, please do not fill out this form, call 911.

 
 
 
Request a Consultation
First Name: *    Last Name *
  
Date of Birth: *
Daytime Phone: *    Cell Phone:
  
Email: *    Confirm Email: *
  
Address:
City:    State:    Zip: *
     
Best way of reaching you: *    Type of Patient: *    Type of Appointment: *
  
  
  
  
Reason for Appointment:
 *
     
     
 
If other, please specify:    Who may we thank for referring you?
  
Preferred day (Check all that apply) *    Preferred Time:
     
     
  
     
   
NewTrend Medical Spa 270 Center Dr., Suite #200, Vernon Hills, IL 60061 (847) 242-1737
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