Phone

903.784.1608

Email

info@hayesclinic.com

Opening Hours

Mon - Thurs: 9AM to 12:30PM, 1PM to 5PM Fri: 9AM to 1PM


Important Information: Read before appointment


Please fill out the following form before your appointment:

Please enable JavaScript in your browser to complete this form.
Step 1 of 2
Patient Name
Can We Leave a Message?
Please tick all that apply
Mailing Address

Medical History

Please check if you have any of the following:
Please check if you have any of the past medical history:
Areas of Concern for Botox and/or Filler (Check all that apply):
DISCLAIMER: By typing your name above, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.