The Skin Center

Check out the eBeautyBuzz - Special Savings from The Skin Center

Simply complete the following form and we'll let you know what you can do to improve the health and beauty of your skin. We can send you an email or call you at your convenience…which ever you prefer. Your personal information will remain confidential and will not be shared with any "list" companies. It is against our policy to contact you by phone without your prior request.
*required
*First Name:**
*Last Name:**
*Address:**
*City:**		*State:**	Zip:*
*Date of Birth:**		*Sex:**	Female	Male
*Email:**
*Day Phone:**
*Evening Phone:**
How did you find our website:
What is your skin type?
Oily Oily to Normal Normal Normal to Dry		Dry Combination Problem/Blemished Sensitive
How would you describe your skin?
Very fair/burns easily/never tans Light/will tan but usually burns Light olive/sometimes burns		Olive/rarely burns Dark olive/very rarely burns Black/burn resistant
Check all that apply to your skin.
Facial Lines	fine medium deep
Location of Lines
around my eyes between my brows on my forehead naso-labial folds around my mouth
Sagging skin
none above my eyes under my eyes near my jawline under my chin
Hyperpigmentation
freckles	age spots	birthmarks	melasma
Sun damage
mild	severe
Enlarged pores
isolated	overall
Rosacea
mild	severe
Unwanted hair
facial	body
Broken capillaries
face	neck, chest	body
Spider veins
thigh area	lower leg
Scarring
acne	post-trauma	post surgical
Acne
whiteheads	blackheads	sebaceous cyst
Women Only Are you taking oral contraceptives?		yes	no
Are you pregnant - trying to become Pregnant / lactating?		yes	no
Men Only Do you experience irritation from shaving?		yes	no
Do you often get ingrown hairs?		yes	no
What are your objectives? Click on all that apply
Minimize size of pores Diminish redness / capillaries on the face Lighten hyperpigmented areas Smooth skin texture Restore skin elasticity Eliminate excess skin Diminish under-eye puffiness Diminish flakiness Diminish fine lines and wrinkles quickly over time Undergo treatments with no downtime minimal downtime Have the best treatment regardless of downtime Optimize at-home skin care Look my best for a special day Fuller lips Eyebrow enhancement Diminish cellulite
Check all that apply now or have in the past
		Currently	In the past
Use Retin A
Use Hydroquinone
Take Accutane
Smoke Cigarettes
Sunbathe
Use Sunscreen daily
Prone to cold sores, herpes, fever blisters?
Tendency to develop wide scars or keloids?
Allergies to medications (please list)
Allergies to cosmetic products (please list)
Please contact me via phone During the day In the evening
Please email me
Please E-mail me notices of new developments and special offers as they become available.

All photos and logos contained in this Web site are protected by copyright and may not be copied, linked, or redistributed in any form.
Copyright © 2008, Dominic A. Brandy, MD All Rights Reserved
American Board of Cosmetic Surgery

Wrinkles

Age Spots

Excess Skin

Aging Faces

Unwanted Hair

Rosacea

Acne Scarring

Active Acne

Spider Veins

Body Contouring

Birthmarks

Stretchmarks

Scars

Cellulite

Uneven/Patchy Eyebrows

Thin/Uneven Lips

Hair Loss/Hair Thinning

Underarm Sweating