Post on 26-Mar-2018
___________________________Cosmetic Interest Form
Dear Patient and Friend:
o If you are interested in any of our cosmetic products or services, please take a moment
to fill out your contact information below. If you would like to receive our monthly newsletter and special offers via email/text.
PleaseCheckOne:YesPlease!________NoThankyou__________Name:_______________________________________Date:_______________________________Email:_______________________________________________________________________________HomePhone:_________________________________Cellphone:______________________________PreferredMethodofcontact:____Homephone_____CellPhone____Email_____TextDOB________________Male_____Female_____
Please check any cosmetic services you are interested in learning more about:
o CuteraExcelV:Vascular&Pigmented
Lesionso CuteraGenesis:“HollywoodGlow”
o CuteraExcelV:legveins
o PhotoFacialSkinRejuvenation(IPL)
o LaserHairRemoval
o SkinCareProducts-SkinCeuticals,
NeoStrata,PCASkin,orEltaMD,RDASkin
o DysportorBotoxInjections
o Restylane,RestylaneSilk,Restylane
Lyft,Refyne&Defyne
o Sculptra(Full-FaceVolumeCorrection)
o CustomizedfacialsandPCASkinChemicalPeel
o EclipseMicroneedling:PRP,HA,GF
o Kybella(UpperNeckFatReduction)
o truSCULPT(Non-Invasivefatreduction
andskintightening)
o SmartGraftHairRestorationSurgery
o PRPScalpinjectionsforhairloss/HairGrowthProducts/Capilluslaserlightcap