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drs skincare

Skincare Questionnaire


  Last name

  Mid name

  First name
(For Cosmetic Dermatology patients only.Medical Dermatology patients must be referred by a Doctor.)

I would like to be advised on:
How I can look better for my age.
How I can change something that has been bothering me for years.
How I can look more attractive.
Other:
Have you had a consultation or treatment for a cosmetic procedure before? Yes No

Most days Weekly Monthly

I want to look less angry
I want to look less sad
I want to look less tired
I want a less saggy appearance
I want to look more youthful
I want to look more attractive
I want to look slimmer
I want softer features
How would you rate the quality of your skin?
Poor Fair Good Very Good Excellent
If you could enhance an aspect of your skin, what would you enhance?
Hydration Elasticity Smoothness Colour
Preferred Scent:
Lemon Lavender Vanilla
IPL for Brown Spots
IPL for Redness
Chemical Peels
Physician-GradeSkin Care
Skin Resurfacing for Acne Scarring
Botox Injections
Fillers for Volume Loss
Skin Tightening: Face
Microdermabrasion
Micro-needling
Physician-Grade Skin Care
Skin Resurfacing for Rejuvenation
Non-Surgical Fat Reduction
Skin Tightening: Body
Stretch Marks
Fat Reduction - Chin
Skin Resurfacing for Acne Scarring
Laser Hair Removal
Mole Removal
Lip Enhancement
Scar Revision
Skin Tag Removal
Botox for Excessive Sweating
Skin care products you are currently using:
Product Brand

Dr.Shukla
Online
A drs skincare client
Other
Contact information-
I would like to receive information about promotions, new products, VIP events.
You may contact me for further questions concerning an appointment at your clinic.
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*Signature:
Date:
(Your digital signature (full name) is as legally binding as a physical signature.)