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Cosmetic Satellite Consultation Online

The Cosmetic Consultation Online is a simple questionnaire that is submitted to Face Doctors to determine the right treatment solutions for you.

* Indicates required field

Name *

First

Last

Age *

Email *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Which areas would you like to improve: *

Forehead Lines Frown lines, Number 11's, Angry Lines Crows Feet, Lines outside the eyes Hollowing under the eyes (Tear Troughs) Hollowing of the Temples Hollowing or Sagging of the Cheeks Mishapen or saddle nose deformity Deep crease from outside of nose to corner of mouth Thin Lips and/or Deep Lip Lines Droopy corners of the mouth (Marionettes) Sagging Jowls Weak chin or jawline Moles and lumps on face Acne Scarring Skin Surface and Skin Care Migraines / Fibromyalgia / Chronic Pain Vampire Breastlift Vampire Facial Vampire Facelift Sexual Rejuvenation P Shot Sexual Rejuvenation O Shot Vampire Hair Regrowth

Other *

Past Medical History Contraindications *

Autoimmune Disorders Bleeding Disorders, Blood Thinning Medication, Warfarin, Aspirin Diabetes IDDM Uncontrolled Glaucoma / Eye Disorders Heart Disease. Valvular Disease Or Prosthetic Heart Valves. Rheumatic Fever Immunosuppression Nerve Disorders. MS / Myasthenia Gravis Active Skin Infections eg. Acne, Herpes Inflammatory Skin Disorders Keloid Scarring Pregnancy or Breast Feeding NONE

If yes please explain. *

Any Other Medical Conditions *

Personal. Smoking, Alcohol. If none write NIL. *

Medications. If none please write NIL. *

Drug Allergies (Local Anaesthetic). If none please write NIL *

EXAMINATION DOCTOR/NURSE COMPLETE THIS SECTION. General well being, ethnicity *

Examine Face in Mirror with patient to see what can be achieved. *

Dysport & Botox Relative Contraindications *

Asymmetry Palsy Sig. Brow Ptosis Refer Surgical Ectropian Square Face Pathology Parotid Stones, Infection, Mandibular Tumor Square face Congenital Acromegaly, Kippel Trenaunay Sn

Agreed Treatments *

Take Photographs *

Relaxed Active Frontal Oblique Lateral

Procedure Dosage See Treatment Sheet *

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