Main Line: (334) 671-9445
Medical Aesthetics: (334) 305-1585
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Main Line: (334) 671-9445

Medical Aesthetics: (334) 305-1585

social@estrogenica.com

1458 Whatley Dr, Dothan, AL 36303

Dothan Location

614 N Main St, Enterprise, AL 36330

Enterprise Location

Juvederm® Screening Form

Patient Information

Name
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Treatment Goals

What areas are you considering Juvederm® for?
What are your aesthetic goals?

Medical History

Are you currently pregnant?
Are you currently breastfeeding?
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Do you have a history of any of the following? (Check all that apply)
Have you taken any of the following in the past 7 days?
Have you previously received facial injectables (filler or neuromodulators like Botox)?

Readiness & Expectations

How soon are you looking to get Juvederm® treatment?
Are you okay with mild post-treatment swelling or bruising?
Are you open to combining your filler appointment with other services?
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Consent Acknowledgment

Consent
Name
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In case you’re experiencing visual impairment or any other condition that is protected under the Americans with Disabilities Act or a law akin to it, and you’re interested in discussing accommodations to enhance your experience with this website, kindly get in touch with our Accessibility Manager at (334) 671-9445

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