The Aesthetic Midwife O-Shot® Consultation

This short, confidential form helps us understand your goals and ensure the O-Shot® treatment is right for you. All information is handled with complete discretion and used only for your consultation.

About You

Full Name*

Date of Birth*

Email Address*

Phone Number*

Postcode (optional)

Let’s Talk About Your Goals

What inspired you to enquire about the O-Shot®?

How long have you noticed this concern?

What would you most like to achieve from treatment?

How did you hear about The Aesthetic Midwife?

Health & Medical Background

Are you currently pregnant or breastfeeding? Ongoing medical conditions Pelvic or vaginal surgery (if yes, when and what) Any current infections or skin conditions? Current medications or hormone therapy Allergies (latex, anaesthetic, etc.) Previous similar treatments (PRP, fillers, laser)

Wellness Snapshot

Menstrual status Energy levels (1–5) Libido or sexual wellbeing (1–5) Do you smoke or vape? How often do you drink alcohol? Overall health

Consultation Preferences

Preferred consultation type When would you ideally like to book in? Preferred day or time

Consent & Privacy

O-Shot® Pricing: £850 for a single session or £1,500 for a two-session package.

Consultation Fees: In-clinic £35 · Remote £35 — Deductible from your fee, if you proceed with O-Shot® treatment.

I consent to The Aesthetic Midwife contacting me regarding this enquiry. I confirm the information I have provided is true to the best of my knowledge. I understand this form is for enquiry purposes only and does not replace a medical assessment. Additional notes (optional)

Thank You

Your enquiry has been received. Our clinical team will contact you within 24–48 hours to arrange your private consultation.

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