Name *

First Name

Last Name

Today's Date *

MM

DD

YYYY

Your Date of Birth *

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Cell Phone *

(###)

###

####

Which of the following best describes your skin type? *

(select one)

Always burns, never tans

Always burns, sometimes tans

Sometimes burns, always tans

Rarely burns, always tans

Brown, moderately pigmented skin

Black

Are you currently pregnant or trying to become pregnant? *

Yes

No

Are you currently nursing? *

Yes

No

Do you or any member of your family have a problem with bleeding or forming blood clots? *

Yes

No

Do you or any member of your family have a problem with bruising easily? *

Yes

No

Please check any of the following medical conditions that apply to you:

(select all that apply)

Cancer

Diabetes

High Blood Pressure

Herpes or Cold Sores

Arthritis

Stroke/TIA

Keloid Scarring

Seizure Disorder

Hormone Imbalance

Thyroid Imbalance

Active Infection

Blood Clotting/Tendency to Bruise/Bleed

Eye Problems

Heart Disease/Chest Pain/Heart Murmur

Kidney Problems

Liver Problems

Hepatitis/HIV

Skin Disease/Lesions/Skin Cancer

Do you use SELF-TANNING LOTIONS? *

Yes

No

Have you had any recent tanning or sun exposure that changed the colour of your skin? *

Yes

No

Does your skin develop a darkening or lightening after physical trauma? *

Yes

No

By checking this box, I agree that the above information is complete and accurate to the best of my knowledge *

Checking this box will act as my digital signature

I agree