Injectables self test - La Vie En Rainey

1

How old are you?* This field is required.

Under 18

20-30

30-40

40-50

50+

2

Are you male or female?* This field is required.

Male

Female

3

Do you regularly sunbathe or use tanning salons?* This field is required.

YESNO

4

What does your past cosmetic treatment history look like?* This field is required.

Botox

Facial surgery

Permanent fillers

Juvederm products

Skin tightening

Nothing at the moment

5

Are you pregnant or nursing?* This field is required.

Pregnant

Nursing

Not applicable

6

Do you have any allergies?If yes, tell us about it below. If not, you can just skip to the next question.

7

Do you have any existing skin conditions?If yes, tell us about it below. If not, you can just skip to the next question.

8

True/False: I feel my face has lost some volume or fullness, possibly due to weight loss or aging* This field is required.

True

False

9

When I look at pictures of myself, the one thing that stands out to me most (other than how gorgeous I look!) is...* This field is required.Pick all that apply

Under-eye circles

Flat cheeks

Thin lips

Crow's feet

Forehead lines

Frown lines

10

Is there anything else you’d like our team to know about your beauty goals?If yes, tell us about it below. If not, skip to the next question.

11

What's your name?* This field is required.

First Name

Last Name

12

What's your email?* This field is required.

example@example.com

13

What's your phone number?Please only enter your 10-digit phone number.

(###) ###-####

14

utm_source

15

utm_campaign

16

utm_medium

17

utm_content

18

utm_term