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Lotus
@
QUEENSWAY MEDICAL
A Physician-Led Clinic
(416)-238-6773
1066 The Queensway, Etobicoke, ON M8Z 1P7
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Pre-Assessment Survey
First Name
Email
Last Name
Phone
What specific cosmetic issues are you concerned about? (check all that apply)
Fine lines and wrinkles
Dark under-eye circles
Sagging skin (jowls, “turkey neck” etc…)
Crow’s feet (wrinkles around eyes)
Dark spots (aka sun spots or age spots
Rosacea
Facial Veins
“Eleven’s” (vertical lines in between eyes)
Dull Skin
Dry Skin
Others
Have you tried any products/treatments in the past to fix these concerns? If so, please share:
Yes
No
How would you like to look after treatment? (check all that apply)
I want to look less tired
I want to look less angry
I want to look less sad
I want a less saggy appearance
I want to look more youthful
Would you like to sustain this look after you achieve it?
Yes
No
How long have you been thinking about getting aesthetic treatment?
Past few days
Past few weeks
Past few months
For years
Is there any specific reason or event why you are interested in treatment now?
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