First Name *

Last Name *

Email *

Phone *

Date of birth *

Do you have any other surgical scars? *

Yes

If yes, what are your current scar concerns? *

Raised scars

Dark (hyperpigmented) scars

Hypertrophic/keloid scars

Unsatisfactory appearance

No concerns

Have you performed scar therapy or treatments in the past? *

Yes

What past scar therapy methods have you done? *

Please let us know which non-surgical cosmetic interests you currently have: *

Skin health & maintenance

Fine lines & wrinkles

Dull complexion

Volume loss

Facial imbalance

Jowls

Bruxism/jaw clenching

Hyperhidrosis/excess sweating

Pigmentation/melasma

Sun damage

Rosacea

Thinning eyelashes or eyebrows

Menopause/perimenopause-related skin changes

Other

Have you had any of the following in the past? *

Neuromodulators (Botox, Dysport, etc.)

Dermal fillers (provide examples)

Biostimulators (Sculptra, Radiesse, etc.)

Laser treatments

Microneedling

PRP

Other

Are you interested in a full facial consultation today? *

Yes

I’d like to learn more - please provide comments

(up to 45 minutes, $150 value - offered at no charge to Dr. Horton’s surgical patients)

What are your expectations for our visit? *

Do you have any upcoming special events where you need to look your best? *

If time allows, are you interested in having a treatment, such as neuromodulator today? *

Yes

Please describe your current skincare routine: *

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