Center for Cosmetic and Laser Surgery
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Center for Cosmetic and Laser Surgery
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Home
Blog
Events
Special Offer
Videos
Popular Procedures
Face Lift
Breast Augmentation
Rhinoplasty
Tummy Tuck
Mommy Makeover
PRP & Microneedling Treatments
Otoplasty
Liposuction
Coolsculpting
Laser Skin Resurfacing
About Us
Testimonials
Mission Statement
Patient Information
Patient Medical Form
Finance
Media
Procedures
Face
Breast
Body
Med Spa
Treatment Options
Gallery
Facial Plastic Surgery
Breast
Body
Surgery FAQ
Facial FAQs
Eye & Ear FAQs
Nose & Chin FAQs
Body FAQs
Breast FAQs
Mommy Makeover FAQs
Non-Invasive FAQs
Staff
Meet Our Staff
Med Spa
Botox & Fillers
Chemical Peels
Coolsculpting
Halo
HydraFacial
Microdermabrasion
Microneedling
Photofacial BBL
PRP Treatment for Hair Loss
Contact
Patient Medical Form
Patient’s Name
First Name
Last Name
Age
Email
Medical History
Hypertension
Yes
No
Diabetes
Yes
No
Heart Disease
Yes
No
Skin Cancer
Yes
No
Hypertrophic Scarring (Keloid)
Yes
No
Aspirin/Fish Oil Use
Yes
No
Tobacco Use
Yes
No
Accutane Treatment
Yes
No
Previous Aesthetic Surgery
Yes
No
Please list all medications you are currently taking (perscription, over the counter, or naturopathic):
Please list any know allergies to medications:
Please list all past surgeries:
Please indicate the services that you are interested in. Use the space provided to specify a particular area of concern:
Botox, XEOMIN Injections (Used to treat frown lines & crow’s feet)
Juvederm/Radiesse/Sculptra Injections – indicate area
Laser Resurfacing/Skin Rejuvenation
Face/Neck/Brow Lift
Eyelid Surgery
Nasal Refinement/Nose Surgery
Ultherapy
CoolSculpting
Liposuction – Please indicate area(s)
Breast Augmentation/Breast Lift
Tummy Tuck
Other – please specify
Request a Consultation
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Face Lift
Eye Lift / Brow Lift
Nose Surgery
Neck Lift
Chin & Cheek Implants
Otoplasty
Laser Skin Resurfacing
Botox & Fillers
ThermiAesthetics
Breast Augmentation
Breast Lift
Breast Reduction
Mommy Makeover
Male Breast Reduction
Liposuction
Tummy Tuck
Coolsculpting
Hyperhidrosis
Men’s Room
Non-Surgical Treatment
Testimonials
Mission Statement
Patient Information
Patient Medical Form
Finance
Media
Center For Cosmetic and Laser Surgery
in Naperville & Chicago, IL
1331 W 75th St. #306
Naperville, IL 60540
(630) 851-3223
[email protected]
request aN Appointment
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