60 Second Test - Patient Intake

Full Name *

Email Address *

1. Are you tired of always being late for work, church or social events? *

A. Yes

B. No

2. Would you love like to look your best at the pool, beach , gym, golf course or dance floor? *

A. Yes

B. No

3. Are you tired of applying makeup in a small mirror while trying to drive? *

A. Yes

B. No

4. Are you Physically incapable or having difficulty applying makeup? *

A. Yes

B. No

5. Are you a person who is allergic to conventional makeup? *

A. Yes

B. No

6. Are you a person with oily skin who tends to shed makeup easily? *

A. Yes

B. No

7. Are you a Nurse or Employee who is not allowed to wear makeup while in sterile environments? *

A. Yes

B. No

8. Would you like to not have to purchase eyeliner and lipstick again? *

A. Yes

B. No

9. Are you a burn survivor or a person with flaws or scars in your skin that you would like camouflaged? *

A. Yes

B. No

10. Do you suffer from hair loss due to Cancer or Alopecia that effects your confidence and positive self esteem? *

A. Yes

B. No

11. Would you love to ALWAYS wake up looking GREAT? *

A. Yes

B. No

Jaudon Sunde