Skin Care Analysis

CARE Plastic Surgery Skincare Analysis:

Please fill in the skincare analysis so we may better serve you. Our friendly staff will respond promptly to your inquiry.

Dry or Oily Skin?
 Extremely Dry Dry Oily Dry with Oily Patchy Areas

My skin texture is...
 Smooth, no wrinkles
 Some wrinkles around eyes, and / or lips
 Several wrinkles on face
 Several wrinkles, some loose skin

What skin problems are you interested in correcting?
 (check all that apply)

 Acne (current or acne scars) Pigment Spots (Sun Spots or Melasma) Broken capillaries (Roseaca) Irregular complexion Aging face, sun damage

What skin care products you use the most? Please check as many as appropriate.
 Cleanser Moisturizer Anti-age treatments and Serums Scrubs/Exfoliants Masques Other...

If other...

What is your biggest skin care concern?

Have you received skincare consultations/treatments, microdermabrasion, medical grade facials or laser treatments to the face in the past?

What is your favorite brand of skincare right now?

Your Age Group:
 greater than 60 40-60 18-40 under 18 years

Your Gender:
 Male Female

Medications:
 Birth control pills Accutane Effudex Antibiotics None

Vitamin Intake:
 Always Sometimes Never

Sun Exposure:
 A lot of outdoor activity Moderate outdoor activity Only driving to and from areas. Little direct exposure.

Are there other procedures you would like to discuss? 
(Check all that apply)
 Male & Female Facelift  Male & Female Chin & Jaw Implants  Endoscopic or Coronal Browlift  Eyelid Surgery (upper or lower eyelid) Neck Lift (or neck tightening) Fat Injection  Lip Augmentation Breast Augmentation  Minimal Scar Breast Lift  Breast Reconstruction  Breast Reduction  Leg & Arm Lift  Liposuction  Abdominoplasty  Microdermabrasion Laser Treatments  Acne  BOTOX  Radiesse  Tummy Tuck Liposuction Rhinoplasty Vein & Hair Removal - Laser

Please provide your information so our skincare expert may be in contact with you. Please fill in the appropriate information for better service. All information is confidential.

Your Name (required)

Your Email (required)

Street Address

City

State

Zip

Phone

Additional Notes (if any):