Colorado Dermatology Center

Questionnaire

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

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.)