KLINE DERMATOLOGY INNOVATIVE MEDICINE & FINE AESTHETICS PATIENTNAME: “VEC CREN EPSTEIp) pare: TV An). 11, 2019 Q Acne scarring Q Rash UO Acne/breakouts O Rough, uneven texture Q Abnormal scarring O Psoriasis Q Blotchiness/redness Q Skin cancer Q Dryness Q Spider veins/vascular abnormality Q Eczema Q Submental fullness “double chin” Q Fine lines/wrinkles QO Unwanted hair O Hair loss/thinning hair Q Unwanted/stubborn fat O Laxity/loss of volume U Underarm perspiration Q Moles/abnormal skin growth Q Other (please specify) Q Pigmentation ol EFTA00314097