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Family Physician and Phone
Health history, please check any of the following that apply to you
CancerStrokeCold soresDiabetesAuto immune diseaseWartsHeart DiseaseBlood disordersSkin conditionsLung DiseaseExcessive scarringSkin sensitivitiesNeck or spine DiseaseHirsutismSeizures
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WHAT SERVICES ARE YOU INTERESTED IN LEARNING ABOUT?
Acne/Acne ScarsBotoxFat reductionLaser hair removalSkincare productsFacial FillersCellulite ReductionHair Loss/ RejuvenationLaser treatmentFace liftingBreast correctionLeg Vein TreatmentStretch MarksHair thinningTummy tuckScar revisionMicrodermabrasion/peelsFat reduction – double chinArm liftBotox for Excessive SweatingImproving skin toneNose AugmentationBotox for TMJSkin tighteningLip AugmentationBotox for MigrainesMicro-needlingEyelash Growth (Latisse)Mole Removal
What is the main reason for your visit today?
Have you had a consultation or treatment for a cosmetic procedure before?
How often do you think about wanting a cosmetic procedure?
How do you feel that you look relative to your age?
Which three statements best reflect how you would like to look and feel after the treatment?
I want to look less tiredI want to look less angryI want to look less sadI want a less saggy appearanceI want to look more youthfulI want to look more attractiveI want my face to look slimmerI want softer features
Note: 48 hour notice is required for any cancellations. A $50 charge will be applied to any missed medical appointments and $100 per 10min charged for any missed cosmetic appointments.