(303) 744-1202f
Fax: (303) 744-0418
Facial Questionnaire



Name:
Street Address:
Email Address:
City: State: Zip:
Business Phone: Home Phone: Cell Phone: Fax:
Age: Sex: Male Female Married Divorced Widowed Single

PREVIOUS TREATMENTS:
Retinoic Acid (Retin-A) Dermasanding Brow Lift
Glycolic Acid Microdermabrasion Liposuction
Botox Collagen Fat Transfer (Fat Injection)
Chemical Peel Face Lift Injection of Filler Substances
Dermabrasion Eyelid Lift
Laser Treatment - Vascular Laser
  Pigment Laser
  CO2 Laser
  Cool Touch Laser
  Other Laser

Could you come to Colorado for your Surgery? Yes No

Which days would you be available for your surgery?
Monday Tuesday Wednesday Thursday Friday

Which months would you be available for surgery?
January February March April May June
July August September October November December

How much recovery time would you have available after your surgery
1-2 Days 3-4 Days 5-7 Days Over 7 Days

Would you like to mail photos to us for a free professional opinion letter? Send to:
Colorado Dermatology Center
950 East Harvard Avenue, Suite 630
Denver, Colorado 80210

Do you wish to know the price? For your face, you want the best - not the cheapest! If so, please call (303) 744-1202

If you click below, your personal information and questionnaire will be transmited to the Colorado Dermatology Center(by doing so, you give permission for us to contact you and release your right to privacy in this regard.)