Botox, Fillers & Laser Questionnaire

Botox / Fillers / Laser Questionnaire

You may not have Botox or Fillers if you are pregnant, breastfeeding, or three months after delivery.

You may not have laser if you have a recent tan (sun exposure 4 weeks before treatment) OR are currently taking antibiotics or other skin sensitizing medication.

Past Medical History

Have you ever had any of the following skin conditions?

Have you previously had?

Your Concerns:

Botox / Fillers

Do you have a history of:

In the last 2 weeks have you used:


Areas for hair removal:

In the last 6 weeks have you:

These products can cause reactions with lasers

How did you hear about us?

Book a Consultation

Our professional and experienced medical staff are ready to help you make an informed decision about a wide variety of medical and cosmetic choices. Please fill out this form and we will contact you to schedule a consultation.


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