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Acne Acne Scars Aging Skin Aging Hands Baggy Lids Birthmarks Body Sculpting - Lose Inches Earlobe Rejuvenation Facial Lines and Imperfections Facial Sculpting Inadequate Eyelashes Liquid Facelift Rosacea Scars Sparse Eyebrows Spider Veins Stretchmarks Tattoo Removal Thin Lips Unwanted Hair Wrinkles Roxana F. Barad, M.D. FREE* Skin Analysis Questionnaire Please submit the form or print and fill out the skin analysis questionnaire so we may better serve your skin treatment needs. One of our medical estheticians will contact you to set up an appointment regarding your areas of concern and discuss the many options available to you. *There is a consult fee. However, if you have treatment done that same day, the consult fee will be waived, resulting in a FREE SKIN ANALYSIS. Printable Questionnaire Click to download Call for your Free Skin Analysis 412-683-3358   *Required Field * Name: Mailing Address: * City, State,  Zip.: * Phone:     Fax:    * E-Mail Address: What product(s) or service(s) are you interested in?   Questions or comments?   What is your skin type? (check all that apply) oily dry oily to normal combination normal problem / blemished normal to dry sensitive How would you describe your skin? (check all that apply) very fair / burns easily / never tans light / will tan, but usually burns olive color / sometimes burns olive color / very rarely burns dark olive or light brown / very rarely burns / dark brown / burn-resistant How would you describe your facial lines: fine medium deep What is the location of the undesired facial lines: around eyes between brows on forehead nasoIabial around mouth, chin Are you bothered by sagging skin? Please identify the location(s) below: above the eyes under the eyes near jaw line under the chin Please identify which of the following skin problems affect you: hyperpigmentation (irregular darkening of skin) sun damage enlarged pores Rosacea: broken capillaries spider veins scars Acne: Is it still active? Yes No For women: Are you pregnant? Yes No Are you lactating? Yes No For Men: Do you get irritation from shaving? Yes No Do you get ingrown hairs? Yes No *Cost of Skin Analysis is deducted from your first treatment. There is a $25 consult fee, however, if you have a treatment done that same day, the consult fee will be waived, resulting in a FREE SKIN ANALYSIS. If you only have time for a consult that day, you will be charged $25, but that cost will be deducted from your first treatment, provided it occurs within one month from the date of your consult.

The Aesthetic Laser Center • 4424 Penn Avenue, Suite 102 • Pittsburgh, PA 15224
Providing Laser and Cosmetic Surgery for patients in Pittsburgh and Surrounding Areas of Allegheny County:
Beechview, Bloomfield, Carrick, Northside, Oakland, Chartiers, East Allegheny, East Carnegie, East Liberty, Greenfield, Highland Park,
Lawrenceville, Mount Oliver, Mount Washington, North Shore, North Side, Polish Hill, Point Breeze, Regent Square, Saint Clair,
Sewickley, Shadyside, South Hills, South Oakland, Southside, Squirrel Hill

TREATMENTS
Arasys Ion Magnum • Arasys&Perfector • Blepharoplasty • Botox • Chemical and Skin Peels • CoolBreeze Laser Procedure • Dysport • The Erbium Laser • EVOLENCE • Juvederm • LED Photomodulation • Medlite Laser Toning • Microdermabrasion • Permanent Makeup • Restylane or Perlane • Radiesse • Sclerotherpy • Sculptra * Starlux IPL • Varia Laser Treatments