Colorado Dermatology Center

Questionnaire

Name:

Street Address:

Email Address:

City:

State:

Zip:

Business Phone:

Home Phone:

Cell Phone:

Fax:

Age:

Sex: Male Female

Married Divorced Widowed Single

Where is your excessive sweating? Click on red text for description of treatment

Armpits?
Available Treatment(s): Tumescent Technique, Drysol�, and Iontophoresis

Palms of Hands
Available Treatment(s): Botox�, or Iontophoresis

Soles of Feet
Available Treatment(s): Botox�, or Iontophoresis

Face
Available Treatment(s): Drysol�, or Certain-Dri�

Body or Back
Available Treatment(s): Botox�, Drysol�, or Thoracic Sympathectomy

How bad is your sweating?

Mild to Moderate

Worst When I Exercise Or It Is Hot

Random Times, Especially Under Stress

Debilitating Or Nearly All The Time (Interfering With My Life)

Previous Therapy
Drysol	Certain-Dri
Iontophoresis("Electric Pads")	Thoracic Sympathectomy
Other

Could you come to Colorado for your Surgery Yes No

Would you need insurance coverage (this very seldom covers the tumescent liposuction technique and never covers botox therapy)?
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 procedure, 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.)