Home Patient forms online Patient forms online

Cosmetic Interests

Patient information

Name    

Address

Phone   

Cosmetic Interests

Listed below are minimally invasive treatments offered here in the office. Please read the list below and tell us what procedure(s) you may be interested in. Please check all that apply:


Botox® Cosmetic
AHA and Glycolic peels
Juvedermâ„¢
Skin Rejuvenation
Avage, Retin-A, or Renova
Micro-Dermabrasion
Eyebrow Enhancement
Chemical Peels
Laser Treatments

Hyperpigmentation
Liver Spots/Age Spots
Removing Leg Veins
Facial and Eye Treatments
Hair Removal
Spider Vein Treatments
Removing Facial Veins
Eliminating Underarm Sweating
Other, please specify:
     

Age:

In order to better understand your specific goals, we would like you to answer the following questions on a scale of 1-5 by checking the appropriate number:

When looking at my face in the mirror, I believe I look younger, the same as, or older than my true age?

Younger Than
True Age
Older Than
1 2 3 4 5

When looking in the mirror, I am not concerned, somewhat concerned, or very concerned about the appearance of my wrinkles?

Not Concerned
Somewhat Concerned
Very Concerned
1 2 3 4 5

How did you hear about Dr. Sterry? (Please Mark all that apply)

Liposuction.com ObesityHelp.com Dr. Sterry.com Magazine Seminar Salon

Friend/Relative: Doctor:

If you were referred by a specific person, may we thank them? Yes No

Acknowledgement

Check this box to send this completed form to the email address entered on this form. This will also entitle you to receive our free e-newsletter. We do not share or sell our patients' email addresses to any third party.


This document is also available in PDF format.
cosmetic-interest

Adobe Reader is required to view or download and print PDF format documents.
Get Adobe Reader

These forms are secured by the iron-clad protection of a GeoTrust Quick® SSL Secure Certificate. You should be able to verify that this page is secure by an "https://" prefix in the URL and a key or padlock icon in the browser's status bar.

SSL stands for Secure Sockets Layer. SSL is the standard for creating a secure, encrypted link between a Web server and a browser, thus securing safe passage of your sensitive information. Once a secure connection is established, SSL encrypts all information sent from your browser to the Web server.


Patient information

Detailed health questionaire

Authorization for photo release

HIPAA Notice of Privacy Practices

HIPAA Consent for treatment

Cosmetic Interest Questionnaire