Help us to know what other procedures and treatments are of interest to you!!
Name: __________________________________________________ Date: __________________________
We offer so many exciting and wonderful treatments and procedures that sometimes a patient
coming to our office for a specific treatment may not realize everything that we can do to help
them look and feel their best! Please help us improve our patient satisfaction by telling us what
other procedures or treatments you would like to know more about. Please check off any items
of interest so our providers can tell you more in a private, confidential setting.
Conditions that are of concern or interest
□ Age/ Sun Spots
□ Facial Veins
□ Scars
□ Acne
□ Leg Veins
□ Stretchmarks
□ Acne Scars
□ Loose/sagging skin
□ Unwanted hair
□ Actinic Keratosis
□ Mild stress incontinence
□ Unwanted tattoo
□ Black heads
□ Melasma
□ Vaginal dryness
□ Body Sculpting/ Fat Removal
□ Menopause
□ Venous Lake (purple spot on lip)
□ Breast asymmetry/dimpling
□ Moles
□ Vitaligo
□ Brown Birthmarks
□ Nail fungus
□ Warts
□ Brown Spots
□ Painful intercourse
□ White heads
□ Cherry Hemangiomas
□ Portwine Stain
□ Wrinkles
□ Difficulty with orgasm
□ Red Spots
□ Other (please specify)
□ Dry skin
□ Rosacea
□ Enhanced sexual response
□ Rough skin
□ Enlarged pores
□ Sebaceous Hyperplasia
Specific Treatments that I would like to know more about
□ Accent (Body Sculpting)
□ Microdermabrasion
□ Botox/Dysport/Xeomin
□ The O-Shot (Enhance Orgasm/Reduce Incontinence)
□ CoolSculpting (Body Sculpting)
□ Pelleve (Skin Tightening)
□ eMatrix (Skin Texture)
□ The Priapus Shot
□ Facial Fillers
□ Prolite/IPL (Photorejuvenation)
□ Facials
□ Sclerotherapy (SpiderVeins on legs)
□ Hormone Replacement Therapy
□ Skin peels
□ Laser Hair Removal
□ Total FX/ Ellman (mole and lump removal)
□ Laser Resurfacing
□ UltraSonic Facials
□ Laser Tattoo Removal
□ Vampire BreastLift
□ Lip Enhancement
□ Vampire FaceLift
□ Medical Grade Skin care Products
□ Other