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Injectables Self Test - The Pura Life
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7
Questions
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1
How old are you?
*
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Under 18
20-30
30-40
40-50
50+
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2
Are you male or female?
*
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Male
Female
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3
Are you pregnant or nursing?
*
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Pregnant
Nursing
Not applicable
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4
When I look in the mirror, I'm most concerned about...
*
This field is required.
Pick all that apply
Under-eye circles
Volume loss
Thin lips
Face wrinkles
Sagging skin
Teeth grinding
Flat cheeks
Migraines
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5
What's your name?
*
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First Name
Last Name
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6
What's your email?
*
This field is required.
example@example.com
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7
What's your phone number?
Please only enter your 10-digit phone number.
(###) ###-####
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8
utm_source
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9
utm_campaign
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10
utm_medium
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11
utm_content
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12
utm_term
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