Demographics, Allergies & Sensitivities

* 1. What is your first name?

* 2. What is your last name?

* 3. What is your date of birth? MM/DD/YYYY

* 4. Are you male or female?

* 5. What is your complete address (include city, state, zip)?

* 6. What are your personal email address?

* 7. What is the best number to reach you at?

* 8. Emergency Contact Name and Phone Number

* 9. How did you hear about us? (Longevity offers a $50 reward for every friend you refer that gets a service with us. We want to make sure friends get the credit they deserve!)

* 10. Are you allergic to any medications? If yes, please list medication and reaction:

* 11. If you sustain an injury to your skin such as a cut, burn, or bruise how long does it take to fully resolve without any hyperpigmentation?

* 12. Are you allergic to: Sulfur, Aspirin, or Latex?

* 13. Do you pick at your skin?

* 14. Do you work around chemicals, inks, or tars?

* 15. Have you ever had a bad reaction to dental anesthesia (Novocain)?

* 16. Have you ever had a reaction to anything you put on your face?

* 17. Do you regularly ingest (please select as many as apply)

* 18. Please add the name and phone number of your primary care physician

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25% of survey complete.

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