* Required


*
Name:

   
* Phone Number:
   
* E-mail Address:
 

1. Sex:

Female Male

2. Skin is:
Oily Dry Combination

3. Skin color is:
Very fair, always burn
Light, but may tan
Light to medium
Medium, rarely burns
Medium to dark (Asian, Hispanic)
Dark (African American), never burns


4. Do you have any food or product allergies?
Yes No

5. Do you have sensitive skin?
Yes No

6. What bothers you about your skin?
Large pores
Acne
Facial lines or wrinkles
Pigmented or age spots
Dark circles around eyes
Moles or skin cancers


7. Have you ever had chemical or laser peels?
Yes No

8. Are you currently using Retin A, Glycolic Acid, Benzoyl Peroxide, Vitamin C, AHA's, or Acne medications?
Yes No




 
 
For a consultation CLICK HERE or call (973) 692-9300.
 
Customer Portal Login
 
New Jersey Top Doctors 2010/2011
 
New Jersey Top Doctors 2010/2011
 
The Real Housewives of New Jersey, Season 2: Bubbies Gone Bad.
 
Dr. Kassir on Podbean
 
 
Dr. Kassir on Health radio
 
New Jersey Top Doc
 
 
 
 
 
 
 
 
PATIENT TESTIMONIALS

FRACTIONAL LASER

Dr. Kassir proud to announce "New Fractional Laser Tightens Skin with Minimal Downtime".

Please click here to contact our office and schedule your appointment.


Free Newsletter and Call Back Request!

   
Follow us on:
 
 
 
Home    Dr. Kassir    Procedures    Gallery    FAQ    Patient Forms    Office Policies    Media    Maps    Contact    Terms of Use
Copyright © 2011 Mona Lisa Cosmetic Surgery Center. All Rights Reserved