Cosmetic Interest Questionnaire

COSMETIC INTEREST QUESTIONNAIRE PLEASE COMPLETE THIS FORM ONLY IF YOU ARE INTERESTED IN LEARNING ABOUT SKINCARE OR OTHER COSMETIC SERVICES

Patient Name: Date :

Other than the reason for your appointment today, what additional skincare services or procedures would you like to learn about? Please check all that apply.

We have our providers and aesthetician on staff to assist you in obtaining beautiful skin!

 Skin care advice  Facial veins  Skin care products  Facial redness  Facial Injectables/ Fillers  Brown spots/age spots/freckle  Facial fine lines/wrinkles  Drooping brow  Pampering facials  Drooping eyelids  Thin lips  Facial fullness/drooping  Length of Eyelashes  Mole removal  Fullness of Eyelashes  Neck wrinkles  Darkness of Eyelashes  Make up  Chemical peel  Microdermabrasion  Blotchy skin  Scar revision  Laser correction of redness or dark spots  Laser Hair removal

Please answer the following questions on a scale of 1 to 5 by circling the appropriate number.

When looking at my face in the mirror, I believe I look younger, the same as, or older than my true age. Younger Than True Age Older Than 1 2 3 4 5

When looking in the mirror, I am not concerned, somewhat concerned, or very concerned about the appearance of my wrinkles. Somewhat Not Concerned Very Concerned Concerned 1 2 3 4 5

When looking in the mirror, I am not concerned, somewhat concerned, or very concerned about my complexion. Somewhat Not Concerned Very Concerned Concerned 1 2 3 4 5

If you have interest in learning more about skincare products or services, initial below if can we contact you. Occasionally, this includes invitations to private events offering discounts of skin care products, cosmetic procedures and information. These resources are intended to highlight relevant considerations in a summary manner and should not be construed as individual legal advice. You should consult with legal counsel before acting on information contained in these docu ______Initial ments or toolshere . ifAllergan, you give Inc. us hasapproval retained to thesend services you of BSM Consulting (“BSM”) to develop and manage Allergan informationAccess® on and products BSM is and solely services responsible (including for the content sales) on thisEmail website. address: Neither Allergan, Inc. nor any of its employees, promotions)officers, directors, subsidiaries or affiliates (collectively, the “Allergan Parties”) warrant or guarantee the accuracy, adequacy or current relevance of such content and none of the Allergan Parties are responsible or liable for such cont ent. The information provided on this website does not constitute legal or other professional advice and anyone viewin g this website is encouraged to obtain such advice on issues applicable to their practice or facility. These resources are intended to highlight relevant considerations in a summary manner and should not be construed as individual legal advice. You should consult with legal counsel before acting on information contained in these docu ments or tools . Allergan, Inc. has retained the services of BSM Consulting (“BSM”) to develop and manage Allergan Access® and BSM is solely responsible for the content on this website. Neither Allergan, Inc. nor any of its employees, officers, directors, subsidiaries or affiliates (collectively, the “Allergan Parties”) warrant or guarantee the accuracy, adequacy or current relevance of such content and none of the Allergan Parties are responsible or liable for such cont ent. The information provided on this website does not constitute legal or other professional advice and anyone viewin g this website is encouraged to obtain such advice on issues applicable to their practice or facility.