Read our COVID-19 letter on staff and patient safety. Call 217-398-4856 to book your appointment!
Facebook Profile - Rejuvenis Facial Cosmetic Surgery & Medical Spa instagram - icon
217-398-4856
Trust Your Face To An Expert, Trust Your Face To A Facial Plastic Surgeon

Resource Center

New Patient Forms

Historical Data Sheet



Patient Name *





Which surgical procedure(s) are you interested in?

Rhinoplasty (nose)Forehead liftRemoval of cysts, moles, etcFotoFacial RFFace or Neck LiftCollagen/Botox/Restylane EyelidsScar RevisionLiposuctionProtruding earsSkin ResurfacingSkin CareHair RemovalSkin CancerLip enhancementOther

Other

Have you consulted another doctor in regards to this type of surgical procedure?

YesNo



Are you allergic to Latex?*

YesNo

Any known drug allergies?*

YesNo






A note to our "injectable" (toxin and filler) patients,

Thank you for visiting Rejuvenis Beauty. At Rejuvenis Beauty, patient satisfaction is our first priority. We appreciate your confidence in us, and to our returning patients, your loyalty. To ensure we meet your scheduling needs in this time of higher than usual demand for appointments with Dr. Russo, we ask patients to schedule future appointments well in advance. For our returning patients we recommend you schedule your next appointment at the end of your appointment while checking out.