Patient Name:___________________________________________
Dermatology Institute is committed to educating you on treatments available for your cosmetic
concerns. Please check the areas that you would like information.
___ Lines and Wrinkles
___Acne Scars
___Loose Skins
____Body Contouring or Fat Reduction
___ Sagging eyelids
____Tattoo Removal
___Dark circles under eyes
____ Leg Veins (Varicose/Spider)
___Brown Spots
____Laser Hair Removal
____Neck Rejuvenation
____Hair loss (thinning)
____Facial Veins or Redness
___ I would like to learn how to take better care of my skin or learn about our makeup line.