Are you ready for Botox or other cosmetic procedures? Name(Required) First Last Email(Required) Preferred Phone(Required)Describe your skin texture. Fairly smooth Rough, patchy and discolored in areas Mixed overall and slightly wrinkled Rough, patchy, wrinkled and discolored How often do you tan (not including self tanner)? Never Rarely – special event or trips only Occasionally, like during the summer months Often – I keep a regular base color How often did you tan in your teens and 20s? Never Rarely Occasionally Often How close do you have to be to see your wrinkles or skin issues in the mirror? Right in front of it A foot away 2 -3 feet away At any distance What is your age? 29 or younger 30-39 40-49 50 or older What is your daily facial SPF? 40 or higher 30 20 15 or less How often do you apply sunscreen? More than twice daily Twice daily Once daily Only when I know I’ll be outside or in the sun Do you smoke? No I’m a social smoker or around smokers I did, but I quit Every day Where are the lines/wrinkles on your face? Between my brows On my forehead and around my eyes On my forehead, around my eyes and lips and between my brows On my forehead, around my eyes, lips and in the area between my nose and lower cheek Describe your pores. Barely noticeable Noticeable just around my nose Noticeable all over Prominent and deeper than they used to be After a good eight hours of sleep, you look and feel: Glowing Completely rested Somewhat rested Tired Δ
