FreshTouchLift™ Pre-Consultation Form FreshTouchLift™ is an award-winning multimodality, nonsurgical approach to the face that leaves you looking younger and keeps you looking natural. Name* First Last Date of Birth* MM DD YYYY Phone*Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Area(s) of Concern*How many years younger would you like to look? 2 Years 5 Years 10 Years 15 Years 20 Years How would you describe your current opinion of neuromodulators (Botox-like facial muscle relaxers)? Currently Using Interested Not Interested Which neuromodulators have you used? Botox Dysport Xeomin Which fillers have you experienced before? None Juvederm Radiesse Restylane Sculptra Perlane Voluma Artefill Have you ever used any "significant downtime" resurfacing skin techniques such as a Deep Peel or Fractional CO2 Resurfacing? Yes No If yes, which have you tried? Deep Peel Fractional CO2 Resurfacing Both Have you used non-ablative rejuvenation techniques? Skin peels? IPL/Laser? Yes No If yes, what have you used?Which lasers/resurfacing techniques are you interested? Deep Peel/ Laser Superficial Peel/ Laser Radiofrequency Raised Mole/ Lesion Removal Other Are you interested in eyelash enhancement? Yes No Currently Using Have you ever used anything for eyelash enhancement? If so, what have you used? Latisse Elastilash Eyelash Solution Over The Counter Products I've Never Used Eyelash Enhancement Products Which of the following medical grade skincare products have you used? Tretinoin (Retin-A) Antioxidants Sunscreen Growth Factors I Haven't Used Any Of These Products Are you interested in learning more about our financing options?* Yes No Please let us know if you have a specific time frame in mind (e.g. preparing for an event or summer)*If you have had any previous facial surgeries, please list them below.
