Frisco Dermatologist | Dermatology & Skin Surgery ...



COSMETIC INTEREST QUESTIONNAIRE

Please complete this form only if you are interested in learning about skincare or other cosmetic services

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|Patient Name: | |

|Date : | |

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|Other than the reason for your appointment today, what additional skincare services or procedures |

|would you like to learn about? Please check all that apply. |

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|We have our providers and aesthetician on staff to assist you in obtaining beautiful skin! |

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|Skin care advice |

|Skin care products |

|Facial Injectables/ Fillers |

|Facial fine lines/wrinkles |

|Pampering facials |

|Thin lips |

|Length of Eyelashes |

|Fullness of Eyelashes |

|Darkness of Eyelashes |

|Chemical peel |

|Blotchy skin |

|Laser correction of redness or dark spots |

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|Facial veins |

|Facial redness |

|Brown spots/age spots/freckle |

|Drooping brow |

|Drooping eyelids |

|Facial fullness/drooping |

|Mole removal |

|Neck wrinkles |

|Make up |

|Microdermabrasion |

|Scar revision |

|Laser Hair removal |

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|Please answer the following questions on a scale of 1 to 5 by circling the appropriate number. |

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|When looking at my face in the mirror, I believe I look younger, the same as, or older than my true age. |

|Younger Than |

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|True Age |

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|Older Than |

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|5 |

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|When looking in the mirror, I am not concerned, somewhat concerned, or very concerned about the appearance of my wrinkles. |

|Not Concerned |

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|Somewhat Concerned |

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|Very Concerned |

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|5 |

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|When looking in the mirror, I am not concerned, somewhat concerned, or very concerned about my complexion. |

|Not Concerned |

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|Somewhat Concerned |

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|Very Concerned |

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|5 |

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|If you have interest in learning more about skincare products or services, initial below if can we contact you. Occasionally, this includes invitations to private|

|events offering discounts of skin care products, cosmetic procedures and information. |

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|_______Initial here if you give us approval to send you information on products and services (including sales) promotions) |

|Email address: |

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These resources are intended to highlight relevant considerations in a summary manner and should not be construed as individual legal advice. You should consult with legal counsel before acting on information contained in these documents or tools. Allergan, Inc. has retained the services of BSM Consulting (“BSM”) to develop and manage Allergan Access® and BSM is solely responsible for the content on this website. Neither Allergan, Inc. nor any of its employees, officers, directors, subsidiaries or affiliates (collectively, the “Allergan Parties”) warrant or guarantee the accuracy, adequacy or current relevance of such content and none of the Allergan Parties are responsible or liable for such content. The information provided on this website does not constitute legal or other professional advice and anyone viewing this website is encouraged to obtain such advice on issues applicable to their practice or facility.

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