I feel I look tiredI feel I look angryI feel I don't look contouredI feel I don't look aesthetically pleasingI feel I look my age but have some areas I'd like to improveI feel I look sadI feel I have saggy skinI feel I don't look smoothI feel I look older than my ageI feel I look my age but would like to enhance certain featuresOther

$300 - $1,000 (noticeable improvement)$1,000 - $3,000 (2 – 5 years younger)$3,000 - $5,000 (6 – 8 years younger)$5,000 - $10,000 (9 – 10 years younger)

CashFinancingCredit CardI'd like to discuss my options

ASAPThis MonthThis WeekWould like to discuss options and timeline

DYNAMIC & STATIC WRINKLES

Slight Movement, Very SubtleWrinkle Free, NaturalNo Movement, FrozenUnsure

Returns when pulled (tight)Slightly saggy (loose during movement)Moderately saggy (loose at rest)Very saggy (very loose at rest)

YesYes, and I'd like to learn moreNoNo, but I'd like to learn more

NormalDryCombinationVery saggy (very loose at rest)

NeverSeldomRegularly

If none, please specify "none"

BEFORE ANY TREATMENT IS ADMINISTERED, PLEASE
ACKNOWLEDGE THE FOLLOWING:

Because certain treatments should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep my providers updated as to any changes in my medical profile and understand that there shall be no liability on their part should I fail to do so.

New Patient Intake Form

DYNAMIC & STATIC WRINKLES

SKIN CARE & CONCERNS