Facial Balancing Questionnaire

Preparing for your Upcoming Facial Balancing Consultation

Thank you for entrusting us to take the first step in your facial balancing journey. We realize this is a big investment, and to ensure the best possible outcome, we kindly request that you provide us with the following information.

Alison Kothmann, R.N., B.S.N is a certified Allergan trainer and one of Austin's most accredited Advanced Nurse Injectors with years of experience to help you both look and feel your best!

Why pre-assessments are critical to the BEST outcomes:

This pre-assessment helps me plan and determine your appointment slot. You will receive an estimated plan with the associated costs before your appointment. Receiving your photos allows me to thoroughly assess your face and tailor a plan that is specifically designed for optimal results.

What to expect after your pre-assessment:

Once I receive your pre-assessment photos and understand your top areas of concern, we will be able to generate a cost estimate.

Afterward, a comprehensive and detailed in-person consult and treatment on the same day will follow, this will be 1:1 time to review your plan in detail and also make adjustments.

Submitting Pre-assessment Photos (please read):

For Alison to thoroughly assess your face, please take photos with:

Good lighting
Hair tied back (off the face)
No makeup or lipstick
Send any notes on history with any Botox & fillers you have previously treated
List your top (3) areas of concern for us to address (i.e. flattened cheeks, lack of jaw definition)

Facial Balancing Questionnaire

First Name* This field is required.

Last Name* This field is required.

Email* This field is required.

Birthdate (MM-DD-YYYY)

List your top three areas of concern for us to address (e.g. flattened cheeks, lack of jaw definition)

Send any notes on history with any Botox & fillers you have previously had treated.

Please submit three photos so Alison can do a pre-assessment and build a tailored plan for your facial balancing.

Front

30 Degree

90 Degree

This field is required.

By submitting this form, you agree to be contacted by phone, email or text and that any associated call may be recorded for quality and training purposes.*

This field is required.

Submit