What about your skin would you like to improve?

(Please check all that apply)

Frown lines between the brows Significant lines around nose & mouth Tired looking skin Facial hair Acne Freckles

Dry skin Fine lines and wrinkles Rough skin texture Sagging Skin Hyperpigmentation Dark circles under eyes

Are you interested in learning more about the following? *

BOTOX® Cosmetic ( Botulinum Type A)
JUVE'DERM™ injectable gel
Restylane® injectable gel
Other skin care products
Laser Treatments:

• Acne
• Age spots/liver spots
• Facial vein removal
• Spider vein treatments
• Hair removal
• Skin rejuvenation
• Birthmarks
• Leg vein treatment

When looking at my face in the mirror, I believe I look younger, the same as, or older than my 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.

Not Concerned

Somewhat Concerned

Very Concerned

1

2

3

4

5

How did you get to our web site?

Surfing the web
Friend or family member (name)
Physician or other health care provider (name)
Insurance provider (company)
Ad or article (publication)
Seminar or other event (date & location)
Other

Please specify the above:

* Information provided is for the exclusive use of Maine Laser Skin Care, and will not be given out to any third party.