Online Skin Evaluation | FREE at Aurora Medical Spa in Des Peres, MO

CALENDAR
OF EVENTS

May 2013
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ONLINE SKIN EVALUATION

*Name:	Name is required.
*Phone:	A value is required.Invalid format.
*Email:	Email address is required.Invalid format.

What is your age?

Under 30
30-40
41-50
51-60
61+

Do you smoke?

Yes
No

Do you lay out in the sun or tanning beds?

Yes
No

How satisfied with your skin are you?

Very Satisfied
Satisfied
Somewhat Satisfied
Not Satisfied

What is it about your skin/face that bothers you THE MOST?

Age Spots/Sunspots
Freckles
Rosacea
Visible Veins
Melasma
Dry Skin
Oily Skin

Acne
Wrinkles between eyes
Wrinkles around mouth (smile lines)
Wrinkles above lips (vertical)
Crows Feet
Small Lips

What is it about your skin/face that bothers you SECOND MOST?

Age Spots/Sunspots
Freckles
Rosacea
Visible Veins
Melasma
Dry Skin
Oily Skin

Acne
Wrinkles between eyes
Wrinkles around mouth (smile lines)
Wrinkles above lips (vertical)
Crows Feet
Small Lips

What is your skin type?

Normal
Dry
Oily

What is your skin tone?

Very fair
Fair
Medium
Dark
Very dark

Please describe anything else to us with a short statement

One of our staff will get in touch with you very soon to discuss the selections on our goals assessment survey. Thank you for taking the time to complete this brief questionnaire. For immediate assistance please call us directly!

Aurora Medical Spa • Call 314-822-1060 • 13319 Manchester Road, Des Peres, MO 63131

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advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health care provider.