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Rotana MedSpa
Take a few moments to fill out this form so that we may better classify your skin problems.
Gender :
*
Male
Female
What skin problems concern you ?
*
Acne
Blackheads
Wrinkles
Dry Skin
Red Discoloration
Textural Changes
Skin Lesions or Spots
Brown Discoloration
Unwanted Hair
Broken capillaries
Sun damage
Flaky skin
Other
When exposed to 30 minutes of mid-day summer sun, does your skin :
*
Always burn
Usually tans, occasionally burns
Burn, then tan
Always tans
Have you recently used any self-tanning lotions, creams or treatments?
*
Yes
No
Have you ever had an allergic reaction to any of the following?
*
Cosmetics
Medicine
Fragrance
Sunscreens
Animals
Iodine
Other
Within the last year, have you been under a dermatologist’s or other physician’s care?
*
Yes
No
Future Appointments/Contact:
May I call you at contact number to confirm future appointments?
*
Yes
No
Your Company Name
Facebook
Twitter
Linkedin
Google+
A brief intro is always great. It's Helps people to identify your company.
Address
[email protected]
800-555-0101
yoursite.com