• VIP Skin Survey

  • WANT TO FIND OUT WAYS TO RENEW YOUR SKIN? BEAUTIFUL SKIN STARTS HERE!

    Complete this quick skin survey to discover your personalized skin solutions. Once completed, you will be given a chance to receive a discount for a new skincare service. Begin your journey for a younger and more vibrant you!

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  • Answer a few simple questions and you will receive options often recommended by physicians to help several skin conditions. For educational purposes only. Submit at the end to receive a copy to your email. Be sure to check your spam or junk folder. Free to take as many times as you wish. Info will never be shared, is securely encrypted and HIPAA compliant.
  • Date*
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    2 digit month, 2 digit day, 4 digit year
  • SELECT YOUR GOAL FOR SKIN IMPROVEMENT*
  • Page 1

  • Your Goal: Reduce fine lines, clogged pores and blemishes

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  • Where do you see these fine lines, clogged pores or blemishes? You may choose multiple areas.*
  • Do you see any of these conditions around the eyes? Check all that apply.*
  • Do any of these concern you about your cheeks? Select all that apply.*
  • Do you have any of these skin problems on your nose?*
  • What type of blemishes are there around your mouth and chin?*
  • Do you have any concerns about your forehead? If so, what are they?*
  • Click next for some good options for these concerns.
  • Page 2 of 14

  • How to address your fine lines, clogged pores and blemishes. Here are some good options.

    These interventions may help improve these conditions.
  •  

  • Click next for some more options. Hit submit at the end to receive a copy to your email.
  • Page 3 of 14

  • How to address your fine lines, clogged pores and blemishes. Here are some more good options.

    These interventions may help improve these conditions.
  • Click next for some more options. Hit submit at the end to receive a copy to your email.
  • Page 4 of 14

  • How to address your fine lines, clogged pores and blemishes. Here are some more good options.

    These interventions may help improve these conditions.
  • Click next for some more options. Hit submit at the end to receive a copy to your email.
  • Page 5 of 14

  • How to address your fine lines, clogged pores and blemishes. Here are some more good options.

    These interventions may help improve these conditions.
  •  

    Life Extension Ceramides

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  • References:

    1.Nagata C, Nakamura K, Wada K, Oba S, Hayashi M, Takeda N, Yasuda K. Association of dietary fat, vegetables and antioxidant micronutrients with skin ageing in Japanese women. Br J Nutr. 2010 May;103(10):1493-8. 

    2.Cho S, Lee DH, Won CH, Kim SM, Lee S, Lee MJ, Chung JH. Differential effects of low-dose and high-dose beta-carotene supplementation on the signs of photoaging and type I procollagen gene expression in human skin in vivo. Dermatology. 2010;221(2):160-71. 

    3.Soft Gel Technologies, Inc. Phyto-derived ceramides, New Ingredient Notification. April 2, 2004. 

    4.Guillou S, Ghabri S, Jannot C, Gaillard E, Lamour I, Boisnic S.The moisturizing effect of a wheat extract food supplement on women’s skin: a randomized, double-blind placebo-controlled trial. Int J Cosmet Sci. 2011 Apr;33(2):138-43.

    5.Asai S1, Miyachi H. Evaluation of skin-moisturizing effects of oral or percutaneous use of plant ceramides. Article in Japanese. Rinsho Byori. 2007 Mar;55(3):209-15. 

    6.Proksch E, Schunck M, Zague V, Segger D, Degwert J, Oesser S. Oral intake of specific bioactive collagen peptides reduces skin wrinkles and increases dermal matrix synthesis. Skin Pharmacol Physiol. 2014;27(3):113-9. 

    7.Beer C, Wood S, Veghte RH. A randomized, double-blind, placebo-controlled clinical trial to investigate the effect of Cynatine(®) HNS on skin characteristics. Int J Cosmet Sci. 2013 Dec;35(6):608-12. 

    8.Marini A, Grether-Beck S, Jaenicke T, Weber M, Burki C, Formann P, Brenden H, Schönlau F, Krutmann Pycnogenol® effects on skin elasticity and hydration coincide with increased gene expressions of collagen type I and hyaluronic acid synthase in women. Skin Pharmacol Physiol. 2012;25(2):86-92.

  • Click next for some more options. Hit submit at the end to receive a copy to your email.
  • Page 6 of 14

  • How to address your fine lines, clogged pores and blemishes. Here are some more good options.

    These interventions may help improve these conditions.
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  • 5. Good: Hormone Replacement if Perimenopausal.
  • Click next for some more options. Hit submit at the end to receive a copy to your email.
  • Page 7 of 14

  • How to address your fine lines, clogged pores and blemishes. Here are some even better options.

    These interventions may help improve these conditions.
  •  

     

  • Click next for some more options. Hit submit at the end to receive a copy to your email.
  • Page 8 of 14

  • How to address your fine lines, clogged pores and blemishes. Here are some even better options.

    These interventions may help improve these conditions.
  •  

     

     

  • Click next for some more options. Hit submit at the end to receive a copy to your email.
  • Page 9 of 14

  • How to address your fine lines, clogged pores and blemishes. Here are some even better options.

    These interventions may help improve these conditions.
  •  

     

  • Click next for some more options. Hit submit at the end to receive a copy to your email.
  • Page 10 of 14

  • How to address your fine lines, clogged pores and blemishes. Here are some even better options.

    These interventions may help improve these conditions.
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  • Click next for some more options. Hit submit at the end to receive a copy to your email.
  • Page 11 of 14

  • How to address your fine lines, clogged pores and blemishes. Here are the best options.

    These interventions may help improve these conditions.
  •  

     

  • Click next for some more options. Hit submit at the end to receive a copy to your email.
  • Page 12 of 14

  • How to address your fine lines, clogged pores and blemishes. Here are the best options.

    These interventions may help improve these conditions.
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  • Click next for some more options. Hit submit at the end to receive a copy to your email.
  • Page 13 of 14

  • Great Job! You have completed this VIP Skin Survey and have learned about many solutions.

    After seeing these possible solutions, you may now have questions answered in person at a free consultation at our clinic in Gainesville, FL.
  • Select your answer below to receive your discount.*
  • Submit here to receive a copy of the VIP Skin Survey in your email

  • Your Goal: Smooth eye bags, fix wrinkles around the eyes, eyebrow lift or get rid of forehead wrinkles.

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  • How severe are your eyebags or tear troughs?*
  • Do you see any crows feet around the eyes? Check all that apply.*
  • Are you happy about your eyebrows?*
  • Have you noticed any forehead lines, frown lines or "11" lines?*
  • Click next for some good options for these concerns.
  • Page 2 of 7

  • Your Goal: Smooth eye bags, fix wrinkles around the eyes, eyebrow lift or get rid of forehead wrinkles. Here are some good options.

    These interventions may help improve these conditions.
  •  

  • Click next for some more options. Hit submit at the end to receive a copy to your email.
  • Page 3 of 7

  • Smooth eye bags, fix wrinkles around the eyes, eyebrow lift or get rid of forehead wrinkles. Here are some even better options.

    These interventions may help improve these conditions.
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  • Click next for some more options. Hit submit at the end to receive a copy to your email.
  • Page 4 of 7

  • Smooth eye bags, fix wrinkles around the eyes, eyebrow lift or get rid of forehead wrinkles. Here are the best options.

    These interventions may help improve these conditions.
  •  

     

  • Click next for some more options. Hit submit at the end to receive a copy to your email.
  • Page 5 of 7

  • Smooth eye bags, fix wrinkles around the eyes, eyebrow lift or get rid of forehead wrinkles. Here are the best options.

    These interventions may help improve these conditions.
  • Click next for some more options. Hit submit at the end to receive a copy to your email.
  • Page 6 of 7

  • Great Job! You have completed this VIP Skin Survey and have learned about many solutions.

    After seeing these possible solutions, you may now have questions answered in person at a free consultation at our clinic in Gainesville, FL.
  • Select your answer below to receive your discount.*
  • Submit here to receive a copy of the VIP Skin Survey in your email

    *Repeat this survey as needed to select additional goals.

  • Your Goal: Remove dark spots, decrease indented scars, or reduce pigmentation changes.

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  • What type of pigment changes do you see on your skin?*
  • What kind of scars do you have? Check all that apply.*
  • Do you have facial hair and how does it affect your appearance?*
  • Where are most of the dark spots or pigment changes on the face?*

  • Do you have active acne?*
  • Click next for some good options for these concerns.
  • Page 2 of 8

  • Remove dark spots, decrease indented scars, or reduce pigmentation changes.

    These interventions may help improve these conditions.
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  • Click next for some more options. Hit submit at the end to receive a copy to your email.
  • Page 3 of 8

  • Remove dark spots, decrease indented scars, or reduce pigmentation changes.

    These interventions may help improve these conditions.
  •  

     

     

  • Click next for some more options. Hit submit at the end to receive a copy to your email.
  • Page 4 of 8

  • Remove dark spots, decrease indented scars, or reduce pigmentation changes.

    These interventions may help improve these conditions.
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  • Click next for some more options. Hit submit at the end to receive a copy to your email.
  • Page 5 of 8

  • Remove dark spots, decrease indented scars, or reduce pigmentation changes.

    These interventions may help improve these conditions.
  •  

     

  • Click next for some more options. Hit submit at the end to receive a copy to your email.
  • Page 6 of 8

  • Remove dark spots, decrease indented scars, or reduce pigmentation changes.

    These interventions may help improve these conditions.
  •  

     

  • Click next for some more options. Hit submit at the end to receive a copy to your email.
  • Page 7 of 8

  • Great Job! You have completed this VIP Skin Survey and have learned about many solutions.

    After seeing these possible solutions, you may now have questions answered in person at a free consultation at our clinic in Gainesville, FL.
  • Select your answer below to receive your discount.*
  • Submit here to receive a copy of the VIP Skin Survey in your email

    *Repeat this survey as needed to select additional goals.

  • Your Goal: Get rid of unwanted facial hair, body hair, or ingrown hairs.

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  • Where would you like the hair removed?*
  • How do you remove the hair right now?*
  • Do you have facial hair and how does it affect your appearance?*
  • Do you have any ingrown hair?*
  • Click next for some good options for these concerns.
  • Page 2 of 4

  • Your Goal: Get rid of unwanted facial hair, body hair, or ingrown hairs.

    This intervention may improve this condition.
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  • Best: Laser Hair Removal.
  • Hit submit at the end to receive a copy to your email.
  • Page 3 of 4

  • Great Job! You have completed this VIP Skin Survey and have learned about many solutions.

    After seeing these possible solutions, you may now have questions answered in person at a free consultation at our clinic in Gainesville, FL.
  • Select your answer below to receive your discount.*
  • Submit here to receive a copy of the VIP Skin Survey in your email

    *Repeat this survey as needed to select additional goals.

  • Your Goal: Decrease smile lines and laugh lines around the mouth.

    These interventions may improve this condition.
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  • What type of smile lines do you have?*
  • If you have smile lines, when do these lines show up?.*
  • Click next for some good options for these concerns.
  • Page 2 of 6

  • Decrease smile lines and laugh lines around the mouth.

    These interventions may help improve these conditions.
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  • Click next for some more options. Hit submit at the end to receive a copy to your email.
  • Page 3 of 6

  • Decrease smile lines and laugh lines around the mouth.

    These interventions may help improve these conditions.
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  • Click next for some more options. Hit submit at the end to receive a copy to your email.
  • Page 4 of 6

  • Decrease smile lines and laugh lines around the mouth.

    These interventions may help improve these conditions.
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  • Click next for some more options. Hit submit at the end to receive a copy to your email.
  • Page 5 of 6

  • Great Job! You have completed this VIP Skin Survey and have learned about many solutions.

    After seeing these possible solutions, you may now have questions answered in person at a free consultation at our clinic in Gainesville, FL.
  • Select your answer below to receive your discount.*
  • Submit here to receive a copy of the VIP Skin Survey in your email

    *Repeat this survey as needed to select additional goals.

  • Your Goal: Add back some volume to the cheeks, increase size of lips, or change shape of face areas

    These interventions may improve this condition.
  • Which areas are you looking to improve? Check all that apply*
  • Click next for some good options for these concerns.
  • Page 2 of 4

  • Add back some volume to the cheeks, increase size of lips, or change shape of face areas

    These interventions may help improve these conditions.
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  • Hit submit at the end to receive a copy to your email.
  • Page 3 of 4

  • Great Job! You have completed this VIP Skin Survey and have learned about many solutions.

    After seeing these possible solutions, you may now have questions answered in person at a free consultation at our clinic in Gainesville, FL.
  • Select your answer below to receive your discount.*
  • Submit here to receive a copy of the VIP Skin Survey in your email

    *Repeat this survey as needed to select additional goals. 

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