Social Security # (optional):     Date of Birth:  

Last Name: First Name:  

Street Address:  

City:   State:   Zip Code:  

Home Phone:   Work Phone:  

Sex:   Male   Female                    Race: African-American Asian Caucasian Hispanic Other

E-mail Address:  

PLEASE CHECK EACH OF THESE COMMON CONDITIONS YOU MAY HAVE:

Acid Indigestion - Heartburn

Acne

Arthritis

Atopic Allergies (Allergic to products applied to the skin)

Constant Runny/Stuffy Nose

Constipation

Dandruff

Denture Wearer

Diabetes

Diarrhea

Dry Skin (Face or Hands)

Fair Skin (Sunburn easily within 30-45 minutes at first exposure)

Foot Problems (corns, ingrown nails, athlete's foot, etc.)

Headaches

Hemorrhoids

Oily Skin

Overweight (10 pounds or more)

Psoriasis

Seasonal Allergies

Smoker

Tan (NOT BURN) Easily

Trouble Sleeping

Underweight (10 pounds or more)

Use a Depilatory (Hair-removing cream, lotion, foam, etc.)

Use Antihistamines Reqularly

Use Cosmetics Regularly

Use Hair Coloring products or would try such products

PLEASE CHECK TYPES OF STUDIES YOU WOULD LIKE TO PARTICIPATE IN:

6-Week Patch Test for Allergic Reactions to Skin Care Products (15 Visits)

1-Week or 2-Week Patch Test for Allergic Reactions to Skin Care Products

Study to Test Products at Home

Ultraviolet Light Study for People who Tan Easily

Ultraviolet Light Study for People who Sunburn Easily

Please check your form to make sure the information is correct, then submit.