Silk'n Hair Removal System - October 2018

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* 1. Please tell us your age:

< 18

18 - 30

31 - 40

41 - 50

> 50

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* 2. Please tell us your gender:

Male

Female

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* 3. To determine your eligibility to test this product, please answer the questions below.

	Yes	No
Are you Pregnant or nursing?	Are you Pregnant or nursing? Yes	Are you Pregnant or nursing? No
Have you been exposed to tanning machines or unprotected sun bathing in the in last 28 days?	Have you been exposed to tanning machines or unprotected sun bathing in the in last 28 days? Yes	Have you been exposed to tanning machines or unprotected sun bathing in the in last 28 days? No
Do you have a history of keloid scar formations?	Do you have a history of keloid scar formations? Yes	Do you have a history of keloid scar formations? No
Any known sensitivity to light or taking medication making you sensitive to light, including non-steroidal anti-inflammatory agents?	Any known sensitivity to light or taking medication making you sensitive to light, including non-steroidal anti-inflammatory agents? Yes	Any known sensitivity to light or taking medication making you sensitive to light, including non-steroidal anti-inflammatory agents? No
Have you treated with Accutane within last 6 months?	Have you treated with Accutane within last 6 months? Yes	Have you treated with Accutane within last 6 months? No
Do you suffer from epilepsy?	Do you suffer from epilepsy? Yes	Do you suffer from epilepsy? No
Have you received radiation or chemotherapy treatment in the past 3 months?	Have you received radiation or chemotherapy treatment in the past 3 months? Yes	Have you received radiation or chemotherapy treatment in the past 3 months? No
Do you have an active implant, such as pacemaker, incontinence device, insulin pump, etc.?	Do you have an active implant, such as pacemaker, incontinence device, insulin pump, etc.? Yes	Do you have an active implant, such as pacemaker, incontinence device, insulin pump, etc.? No
Do you have eczema, psoriasis, lesions, open wounds or active infections, such as cold sores in the area being treated?	Do you have eczema, psoriasis, lesions, open wounds or active infections, such as cold sores in the area being treated? Yes	Do you have eczema, psoriasis, lesions, open wounds or active infections, such as cold sores in the area being treated? No
Do you have a history of skin cancer or area of potential skin malignancies?	Do you have a history of skin cancer or area of potential skin malignancies? Yes	Do you have a history of skin cancer or area of potential skin malignancies? No

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The hair removal systems work differently depending on skin tone and hair color. Please indicate in the next question which number most closely resembles your skin tone.

The hair removal systems work differently depending on skin tone and hair color.  Please indicate in the next question which number most closely resembles your skin tone.

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* 4. Please select the number that most closely matches with your skin tone

1

2

3

4

5

6

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Please indicate in the next question which hair color most closely resembles your NATURAL hair color.

Please indicate in the next question which hair color most closely resembles your NATURAL hair color.

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* 5. Please select the number that most closely matches your NATURAL hair color.

1

2

3

4

5

6

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* 6. Please complete the information below to qualify for this opportunity.

Name *

State/Province *

Country *

Email Address *

Phone Number

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* 7. Are you currently a registered member of our community?

Yes

No