Click To View Results of Treatment of Acne Scars by Dr. Swinehart

PROCEDURES PERFORMED Click for more information! Punch Grafting Dermal Grafting Subcision Autologous Collagen Fat Injection Dermasanding Dry Ice Microdermabrasion Laser Treatment

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Name:

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Business Phone: Home Phone: Cell Phone: Fax:

Age: Sex: Male Female Married Divorced Widowed Single

What type of scars do you have? Click For Link Click For Description of Possible Methods of Treatment Large Firm Pits(Large Pores) Before and After Photos Punch Grafting/Punch Elevation 1/8 inch to 1/4 inch Firm Soft Scars Before and After Photos Collagen-Autologous(Your Own) Collagen - Bovine(Zyderm® ; Zyplast® ) Subcision or Dermabrasion Broad Soft Scars (over 1/4 inch wide) Before and After Photos Punch Grafting Fat Injection Dermal Grafting Pigment Scars - Light Dark Before and After Photos Dermabrasion Dermasanding Approximate Number of scars on each cheek? 1-3 4-6 7-10 Greater than 10 Approximate Number of scars on nose? 1-3 4-6 7-10 Greater than 10 Approximate Number of scars on chin? 1-3 4-6 7-10 Greater than 10 Approximate Number of scars on forehead/temples? 1-3 4-6 7-10 Greater than 10

PREVIOUS TREATMENT FOR SCARS: Microdermabrasion Collagen or Other Injections Laser Dry Ice Dermabrasion Other Chemical Peels Dermasanding

DO YOU HAVE ACTIVE ACNE? Yes No

Mild Moderate Severe

PRESENT TREATMENT FOR ACNE:

Oral Antibiotics Tropical Antibiotics Tazorac Gel Other (List) Retin-A Benzoyl Peroxide Sulfur Preparations Azaleic Acid Differin or Finevin Peels

PRICE? Do you want the cheapest treatment? Or the Best? Call (303)744-1202

Could you come to Colorado for your Surgery? Yes No

Which days would you be available for your surgery?

Monday Tuesday Wednesday Thursday Friday

Which months would you be available for surgery?

January February March April May June July August September October November December

Would you like to mail photos to us (we do not accept e-mail of digital photos) for free opinion letter? Send to:

Colorado Dermatology Center 950 East Harvard Avenue, Suite 630 Denver, Colorado 80210

If you click below, your personal information and questionnaire will be transmited to the Colorado Dermatology Center(by doing so, you give permission for us to contact you and release your right to privacy in this regard.)