Cosmetic Interest Questionnaire Columbus

First Name	Last Name
Phone Number	E-Mail Address

Procedures, Products and Body Areas of Concern or of Interest to You (please check all that apply).
Skin care advice Skin care products BOTOX® Cosmetic Juvéderm/Restylane/Radiesse Facial fine lines/wrinkles Laser skin resurfacing Thin lips Blotchy skin Chemical peel Make up Unwanted hair	Facial veins Facial redness Brown spots/age spots/freckles Drooping brow Drooping eyelids Nose size or shape Ear size or shape Facial fullness/drooping Mole removal Scar revision Neck wrinkles Breast size Abdominal area Hips Legs Facial Contouring Body Contouring
Other:

Please answer the following questions on a scale of 1 to 5 by circling the appropriate number.
When looking at my face in the mirror, I believe I look younger, the same as, or older than my true age.
Younger Than		True Age		Older Than
1	2	3	4	5
When looking in the mirror, I am not concerned, somewhat concerned, or very concerned about the appearance of my wrinkles.
Not Concerned		Somewhat Concerned		Very Concerned
1	2	3	4	5

How did you hear about us?
My physician	Full name:
My insurance company provider	Name:
The yellow pages	Specify Ad:
A friend or family member	Name:
Internet
Columbus Aesthetic & Plastic Surgery Web site
Seminar	Date & Location:
Cosmetic Surgery Network
Other	Please specify:

Are you interested in meeting with one of our professional staff in order to create a Personal Treatment Plan designed to meet your cosmetic needs?
Yes No

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