Patient Concern

Anti-Aging

Skin Tone/Texture

Facial Balancing

Other

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, make up free digital photos of your face and neck for our team to review. These high-quality photos are essential for accurate remote assessments.

*PDF or JPG Files only (Total File Size must be under 20mb)

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.*

Front*

Left Profile*

Right Profile*

Left Oblique*

Right Oblique*

Non-Surgical Consultation Request with Dr. Roskies

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