COSMETIC INTEREST QUESTIONNAIRE
(OPTIONAL)
SKIN CARE ADVICE
 SKIN TAGS
SKIN CARE PRODUCTS
 LASER HAIR REMOVAL
SUN PROTECTION
 PRODUCTS/TREATMENTS
ANTI AGING
BOTOX FOR WRINKLES
 SUN SPOTS/ AGE SPOTS
BOTOX FOR SWEATING PROBLEMS
 COSMETICS
GLYCOLIC (SUPERFICIAL) CHEM PEEL
 DRY SKIN / MOISTURIZERS
TCA (MEDIUM) CHEMICAL PEELS
 RESTYLANE/DERMAL FILLERS
TREATMENT FOR SPIDER VEINS
 ENLARGED OIL GLANDS
EXCESSIVE HAIR
Please note:  If we find that your questions will require extra time to address we may need to
schedule you for an additional or follow up visit so we can address all your interests and
concerns properly.  

May we mail you information regarding our products or services?   YES____  NO____   INITIALS_____