Dermatology

Cosmetic

Laser

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Cosmetic Interest Questionnaire

Our goal at Attleboro Dermatology is to respond to all of our patients' needs and to provide the highest quality care. In order to provide the information and services you desire on the health and appearance of your skin, we invite you to complete the following questionnaire.

I am interested in (check all that apply):

Fields in RED are required. Please fill in all applicable fields. You do not need to print out this form.

Wrinkles

Forehead lines

Frown lines

Crow's feet

Nose-to-Mouth lines

Lines around mouth

Lines above lips


Volume Loss

Tired look under the eyes

Facial drooping

Flattening of the cheek

Lips appearing smaller

Folds around downward corners of mouth


Brown/Liver/Age Spots

Face

Neck/Chest

Hands


Veins/Blood Vessels

Face

Legs

Other


Other Concerns

Rosacea

Sun damaged skin

Double Chin

Skin Rejuvenation


Removal of

Facial Moles

Skin tags

Keratosis (scaly growths)


Specific Services

Botox

Voluma

Juvederm

Kybella

Lip Augmentation

VBEAM Laser Treatment (red veins)





AHA and Glycelle Peels

Chemical Peels

Sclerotherapy (leg vein)

BLU Light Treatment

Photodynamic Therapy (skin rejuvenation)

Customized Program

Other (please explain)


How did you hear about Attleboro Dermatology?

Would you like to receive information about any product or service specials?

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