Scar Treatment Evaluation Form
Please provide the following information to help us assess your scar and recommend the best treatment options.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
How did you hear about our clinic?
Please Select
Internet Search
Social Media
Friend or Family
Physician Referral
Other
Where is the scar located on your body?
*
What type of scar do you have?
*
Please Select
Hypertrophic
Keloid
Atrophic (e.g., acne, chickenpox)
Contracture (from burns)
Stretch Mark
Other
How long have you had this scar?
*
Please Select
Less than 6 months
6-12 months
1-2 years
More than 2 years
What caused the scar?
*
Please Select
Surgery
Injury/Accident
Burn
Acne
Other
Please describe the size and appearance of your scar.
*
Do you experience any of the following with your scar? (Select all that apply)
Pain
Itching
Redness
Swelling
Restricted Movement
None of the above
Have you had any previous treatments for this scar?
*
Yes
No
If yes, please specify the treatments you have tried.
Do you have any known allergies?
*
Yes
No
If yes, please list your allergies.
Are you currently taking any medications?
*
Yes
No
If yes, please list your current medications.
What are your goals or expectations for scar treatment?
*
Please upload a clear photo of your scar (optional)
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