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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






About author - Dr. Russo

Dr. Russo

Dr. Russo is the founder of Rejuvenis Med Spa. He developed a passion for lasers, fillers, and other non-cosmetic treatments during his over 30 years of practice in Champaign-Urbana. He started his career after completing an AAFPRS fellowship in Facial Plastic Surgery. After many years of managing a busy surgical practice and med spa, Dr. Russo focuses his interest and practice on non and minimally-invasive facial and skin rejuvenation. Visit Rejuvenis Beauty today for experienced care in health, beauty, and wellness!

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