Cosmetic Questionnaire
PATIENT INFORMATION
Last Name:
First Name:
M.I.:
Street Address:
City:
State:
ZIP:
Home Phone
Email
Social Sec. #:
Patient #:
QUESTIONAIRE
1.
Are you interested in a cosmetic evaluation(Yes/No)? (If No, then you do not have to fill out this form.)
Yes
No
2.
What cosmetic procedures are you interested in?
Botox/Dysport
Facial fillers (Restylane, Juvederm)
Chemical peels (Salicylic acid or Glycolic peels)
Sclerotherapy (Leg vein injections)
Laser procedures
Skin care products
Other
3.
What cosmetic procedures have you had in the past?
4.
How were the outcomes of your previous procedures?
5.
What areas of your skin are you concern about and why?
SIGNATURE
