Online Test Cosmetic Medicine - Essential Men's Clinic

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Cosmetic Medicine Online Test

Want To Look Better? This is a questionnaire to help men understand the services and treatments available to help them improve
their appearance.

These Online Tests are simple questionnaires that are submitted to our Doctors to see if Essential Men's Clinic has a solution that is right for you. They are obligation free and absolutely confidential.

* Indicates required field

How did you hear about this site? *

Internet Search Advertisement Friend Other

If Other please specify: *

Which Essential Mens Clinic? *

Auckland Remuera Auckland Howick Wellington Central

Name *

First

Last

Age *

Email *

Phone Number *

Region You Reside *

Which areas would you like to improve? Choose as many as you like.

Choose as many as you like *

Forehead Lines Frown lines, Number 11's. Angry lines. Crows feet. Lines outside the eyes. Hollowing under the eyes (Tear troughs) Hollowing of the temples Hollowing or sagging of the cheeks Mishapen or saddle nose deformity Deep crease from outside of nose to corner of mouth (Nasolabial folds) Thin Lips and deep lip lines Droopy corners of the mouth (Marionettes) Sagging jowls Weak chin and jawline Moles and lumps on face and neck, body Acne scarring Skin surface Hair Loss

If you've ticked any of the above please explain further what you would like us to do. Or if we haven't covered what your looking for just write down what you're after.

Further information. What do you want to know. *

Past Medical History. Choose any applicable. *

NO MEDICAL PROBLEMS Asthma Heart Disease Hypertension Diabetes Kidney Disease Glaucoma. Other Eye Disorders Immunosuppression Nerve Disorders. Multiple Sclerosis, Myasthenia Gravis. Active Skin Infections Keloid Scarring Epilepsy Autoimmune Disorders Blood Thinners

If you've chosen any of the above, or have any other medical history then please provide further information. *

Current Medications. Write NIL if no current medications. *

Allergies. Write NIL if no allergies. *

Submit

Our Doctors will respond within 24 hours to your submission from your given email address.
Your personal details will remain confidential and not disclosed to any third parties.
You have the right to view, change or delete this information on request.
This questionnaire is not comprehensive, and does not replace a full history and physical examination and further information may be necessary on follow-up.
Due diligence will be exercised for making a thorough assessment.

Want to know more? Watch this Video:

Face Aesthetics
Wrinkle
Dermal Filler
Dermaroller
IPL-Intense Pulse Light
Mole Removal

Body Aesthetics
Excessive Sweating
Dermaroller
IPL-Intense Pulse Light
Mole Removal

Hair Growth
Pharmaceutical

Man Up Health Check
Man Up

Men's Corner
P Shot® or Priapus Shot®
Sexual Problems
Ejaculatory Problems
Erectile
Dysfunction
Premature Ejaculation
Peyronie's Disease

Essential Men's Clinic
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Home
Priapus Shot®
- Extracorporeal Shock Wave Therapy
Online Tests
Services
About Us
Contact Us
Frequently Asked Questions
Blog