Patient Concern

Anti-Aging

Volume Loss

Facial Balancing

Pigmentation

Skin Tone/Texture

Scarring

What previous treatments have you had performed on your face/neck/body? Choose all that apply.

Botox / Neuromodulators

Hyaluronic Acid Fillers

Sculptra

Radiesse

Ultherapy

Thermage

Fraxel

Thread Lifts

RF Microneedling (e.g. Morpheus8)

Light Therapy for red or brown spots i.e. BBL, IPL

Laser Hair Removal

Permanent Fillers (e.g. Artecoll, Bio-Alcamid)

Patient Attestation I hereby confirm that I have read and understood all of the information provided above. I certify that all answers and personal health information I have disclosed in this form are true, complete, and accurate to the best of my knowledge. I understand that withholding or providing false information affect the care I receive and could result in the cancellation or delay of treatment. I agree to inform the clinic of any changes to my health status or medications before any future procedures or treatments.

We appreciate you taking the time to share this information. Dr. Roskies and his team put a great deal of care and attention to detail into every consultation and procedure. We're thankful for your interest and look forward to speaking with you soon.

To finalize your form, please upload clear digital photos of your face and neck for Dr. Roskies and his team to review. These high-quality photos are essential for accurate remote assessments. For best results, please have someone take your pictures in a room with good natural light and a neutral background. Stand a few feet away from the camera, pull your hair back, and ensure the camera lens is at eye level with your chin parallel to the floor. Make sure both your face and neck are visible in the frame. Thank you!

Please note, communications through our website or via email are not encrypted and are not necessarily secure. By submitting this form, you are granting Dr. Mike Roskies and his team have permission to review your photos. These photos will only be used in-house for consultation purposes.*

Non-Surgical Consultation Request with Dr. Roskies

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