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

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
 My insurance company provider
 The yellow pages
 A friend or family member
 Internet
 Columbus Aesthetic & Plastic Surgery Web site
 Seminar
 Cosmetic Surgery Network
 Other

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