Follow Us!Cosmetic ProceduresBotox and Fillers Botox® Cosmetic Dysport® Xeomin® VOLUMA® XC VOLLURE™ XC VOLBELLA® XC Bellafill® Radiesse® Revanesse® Versa™ Restylane® Restylane® Silk Sculptra® Belotero® Juvederm® Injectable Gel Perlane® Hand Therapy/Rejuvenation Skin Tightening & Body Contouring Local Anesthetic (Tumescent) Liposuction Infini RF Microneedling: Skin Laxity & Texture Kybella™: “Double Chin” Contouring Laser Procedures Laser Photorejuvenation Laser Hair Removal Laser Tattoo Removal Vbeam® Pulsed Dye Laser Skin Cancer Screening & Skin Treatments Chemical Peels Sclerotherapy Scar Revision New Patient Registration Please fill out the form as completely as possible: Name (Nombre)* DOB (Fecha de Nacimiento)* Your Email* Procedures (Procedimientos) Please mark which concerns apply to you? (por favor marcar lo que quisiera mejorar): Brown Spots (machas carmelitas) on face Brown Spots (machas carmelitas) on body Visible exposed blood vessels/capillaries (vasos sanguinos) on face Visible exposed blood vessels/capillaries (vasos sanguinos) on body Wrinling hands (manos envejecidas Dark under eye circles (ojeras) Uppler lip lines (lineas de los labios) Laugh lines (lineas de la risa) Enlarged pores (poros abiertos) Acne (Clogged Pores) Scarring (cicatrices) Skin Laxity (laxitud de piel) Wrinkles (arrugas) Unwanted hair/Laser hair removal (bello no deseado) Leg veins- sclerotherapy (venas varicosa) Skin Care (Cuidado de piel): What is your skin type (Que clase de piel tiene) ? Dry (seca) Combination (Combinacion) Oily (grasosa) Normal (normal) Please check the products you currently use (Porfavor indicar productos que esta usando Facial Cleanser (limpiador de cara) Moisturizer (humectante) Anti-Aging Serum (antienvejecimiento) Sunscreen (bloqueador solar) Eye Cream( crema para ojos) Retinol Scrub (exfoliante) Antioxidant (antioxidantes) Medical History Allergies (alergias) Medication (medicamentos) Are you pregnant (Esta usted en estado) ? Yes No Have you ever had any of the following injectables or implants (Usted alguna vez ha tenido alguno de los siguientes productos injectado)? Botox Dysport Juvederm Restalyne Perlane Radiesse Silikon Sculptra Collagen Prevelle Hylaform Other filler: Have you had an unusual reaction to any of these? (Usted a tenido alguna reacción inusual con algunos de estos productos)? Yes No If so please explain: Tell your doctor about your medical conditions (Por favor déjenos saber sus condiciones médicas): Have you been diagnosed with a disease that affects your muscles and nerves? (Usted esta diagnosticado con un condición que afecta sus músculos o nervios)? Such as (Como estas): Amyotrophic Lateral Sclerosis Yes No Myasthenia Gravis Yes No Lambert Eaton Syndrome Yes No
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