Eyes by Thermage™
Two distinct approaches available
Sclerotherapy
The gold standard for the treatment of spider veins on the legs
Pixel Laser Skin Resurfacing
New at Rejuvene
VolumaLift™
Restore a youthful look in 30 minutes!

Cosmetic Patient Questionnaire

Have you ever had the following:

Are you currently taking birth control pills?	Yes
Are you currently pregnant or lactating?	Yes
Have you ever taken Accutane?	Yes
Please list all medications you are taking, including all herbal preparations:

Are you presently under a physician's care for any condition? If so, please describe:

Do you consume alcohol?	Yes
Do you smoke?	Yes
Do you exercise regularly?	Yes
Do you use tanning booths?	Yes
Describe your history of sun exposure:

	Facial surgery in the past year
	Collagen/Restylane injections
	BOTOX® Cosmetic injections
	Glycolic peels in the past year
	TCA or Phenol peel in the last year
	Electrolysis

Please indicate which of the following products you use:

What conditions currently apply to your skin?

What would you like to achieve with your treatment(s) and/or skin care recommendations?

We hereby advise you, that to prevent the occurrence of undetected skin cancer, you must have a yearly skin evaluation by a dermatologist

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