COSMETIC INTEREST QUESTIONNAIRE
|Patient Name: |Date: |
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|Please check any areas of concern you may have. |
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|Skin care advice |
|Skin care products |
|Injectable Treatments |
|Fillers |
|Fine lines/wrinkles |
|Thin lips |
|Scars |
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|Facial redness |
|Brown spots/age spots/freckle |
|Drooping brows or eyelids |
|Acne |
|Dark Under eye circles |
|Rough Skin Texture |
|Dry Skin |
|Oily Skin |
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|Neck wrinkles/sagging |
|Unwanted Hair |
|Length/Fullness of Eyelashes |
|Blotchy skin |
|Chemical peels |
|Tattoo Removal |
|Lines between the brows |
|Smile Lines around the mouth |
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|Would you like us to teach you how to care for your skin? ___Yes ____No |
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|Do you currently have a skin care regimen? If so, please list the products you use on a regular basis. |
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|______________________________________________________________________________________ |
|______________________________________________________________________________________ |
|______________________________________________________________________________________ |
|______________________________________________________________________________________ |
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|EMAIL LIST |
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|Would you like to become part of our office email list? You will receive a monthly email |
|about office promotions and specials we are offering on products and cosmetics procedures. |
|Don’t miss your chance to save and look great all year round! |
|Special offers only valid through email |
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|( Approval to send you information via email on products and services |
|(including special offers) |
|Email address: |
|Telephone number: |
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|( I’m not interested in any additional services provided at this time |
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