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Cosmetic Interests

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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
Skin Rejuvenation
Avage, Retin-A, or Renova
Eyebrow Enhancement
Chemical Peels
Laser Treatments

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:


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


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Patient information

Detailed health questionaire

Authorization for photo release

HIPAA Notice of Privacy Practices

HIPAA Consent for treatment

Cosmetic Interest Questionnaire