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Anne L. White, M.D.
Carolina Laser & Cosmetic Center
145 Kimel Park, Suite 140
Winston Salem, NC 27103
336-659-2663 or 1-877-WE BOTOX (877-932-6869)
Mon-Thurs 9 - 5, Fri 9-4, Sat By Appointment Only

Consultations can usually be arranged within a few weeks simply by calling us at (336) 659-2663 or 1-877-WE BOTOX (932-6869) or by completing this form. Treatments for some procedures can be performed the same day as consultation. Dr White’s booking fee for your personal treatment consultation is $110. The cost of the booking fee will be deducted from the cost of your procedure if the procedure is performed within 30 days of the consultation. Please note: booking fees are nonrefundable. Booking fee for skin care only is $95.

Please note: This form is for patients and individuals considering treatment only. No business solicitations.

Your Name
State Zip
Daytime Phone
Evening Phone

Are you a patient? Yes No
I want to schedule a consultation Yes No
I want to schedule treatment Yes No
How did you hear about us?

Your concerns and interests (you may choose more than one)
BOTOX® Cosmetic
Other Dermal Fillers Injectables
Facial Lines & Wrinkles
Broken Facial Capillaries
Sun Damage, Age Spots
Birth Marks
Skin Rejuvenation
Skin Resurfacing
Skin Tightening
Hair Removal
Tattoo Removal
Non-Surgical Facelift
Non-Surgical Eyelift
Non-Surgical Chinlift
Laser Facial
Laser Peel
Chemical Peel
Cellulaze Celulite Reduction
Profractional Therapy
BBL Phototherapy
Leg Veins
Earlobe Repair
Vaginal Rejuvenation
Lip Enhancement
Permanent Makeup
Skin Care
Sweat Reduction
Headache Reduction
Other Concerns (please describe)
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