(303) 744-1202f
Fax: (303) 744-0418
Questionnaire

Name:
Street Address:
Email Address:
City: State: Zip:
Business Phone: Home Phone: Cell Phone: Fax:
Age: Sex: Male Female Married Divorced Widowed Single

Where is your excessive sweating? Click on red text for description of treatment
Armpits?  
Available Treatment(s): Tumescent Technique, Drysol®, and Iontophoresis
 
Palms of Hands
Available Treatment(s): Botox®, or Iontophoresis
 
Soles of Feet
Available Treatment(s): Botox®, or Iontophoresis
 
Face
Available Treatment(s): Drysol®, or Certain-Dri®
 
Body or Back
Available Treatment(s): Botox®, Drysol®, or Thoracic Sympathectomy

How bad is your sweating?
Mild to Moderate
Worst When I Exercise Or It Is Hot
Random Times, Especially Under Stress
Debilitating Or Nearly All The Time (Interfering With My Life)

Previous Therapy
Drysol Certain-Dri
Iontophoresis("Electric Pads") Thoracic Sympathectomy
Other

Could you come to Colorado for your Surgery Yes No

Would you need insurance coverage (this very seldom covers the tumescent liposuction technique and never covers botox therapy)?
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

How much recovery time would you have available after your surgery
1-2 Days 3-4 Days 5-7 Days Over 7 Days
Would you like to mail photos to us for a free professional opinion letter? Send to:
Colorado Dermatology Center
950 East Harvard Avenue, Suite 630
Denver, Colorado 80210
Do you wish to know the price? For your procedure, you want the best - not the cheapest! If so, please call (303) 744-1202

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.)