Skin Analysis Survey - Dr. Elizabeth Fox: Naples, Florida's finest plastic surgeons specializing in cosmetic, facelift, tummy tucks, neck lifts, and breast surgery

"Empowering Women, Enhancing Self-Esteem & Confidence"

Fox Plastic Surgery Center
827 Myrtle Terrace
Naples, FL 34103
Map & Directions

239-262-8585

Please use the Skin Analysis Survey below to tell us a little about yourself and your interests. Fill in the appropriate information and press the SUBMIT button. We will respond promptly to your inquiry.

What type of skin do you have?

Dry
Oily
Dry with Oily areas

What is the texture of your skin?

Smooth, no wrinkles
Some wrinkles around eyes, and or lips
Several wrinkles on face
Several wrinkles, some loose skin

What skin problems are you interested in correcting?

(check all that apply)
Acne
Pigment Spots (Sun Spots)
Broken capillaries (Roseaca)
Irregular complexion
Aging face, sun damage

Age group

greater than 60
40-60
20-40
less than 20 years

Gender

Female
Male

Medications

Birth control pills
Accutane
Effudex
Antibiotics
None

Vitamin Intake

Always
Sometimes
Never

Sun Exposure

A lot of outdoor activity
Moderate outdoor activity
Only driving to and from areas. Little direct exposure.

What procedures are you interested in receiving information about?

(Check all that apply)
Male & Female Facelift
Male & Female Chin & Jaw Implants
Endoscopic Browlift
Eyelid Surgery
Neck Lift
Fat Injection
Lip Augmentation
Breast Augmentation
Minimal Scar Breast Lift
Breast Reconstruction
Breast Reduction
Leg & Arm Lift
Total Body Liposuction
Abdominoplasty
Microdermabrasion--Organic (non-aluminum)
Laser Treatments
Acne
BOTOX
Radiesse
Tummy Tuck
Liposuction
Rhinoplasty
Vein & Hair Removal - Laser

How would you like to receive information?

(Check all that apply)
E-Mail
Phone
Postal Mail

Questions

Contact Info

*Name:
*E-Mail address:
Home address:
Phone Number:
*How did you hear about us?

*required

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827 Myrtle Terrace - Naples FL 34103 • 239.262.8585