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Name
*
First Name
Last Name
Email
*
Phone Number
*
Format: (000) 000-0000.
Company
Website
Address
*
Street Address
Apt/Floor/Suite
City
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Brand Importance
*
Quality of active ingredients
Efficacy of products
Profitable for my business
Cost of products
Easy to sell
Well-known brand
Are you planning on selling online?
*
Yes
No
What is the majority age group of your clientele?
*
0-22
22-35
35-50
50-60
60+
What is your professional background?
*
Esthetician
Cosmetologist
Med Spa
Doctor
Registered Nurse
Student
Business Owner/Director
Other
What areas you looking to improve in your practice? Please check all that apply.
*
New Peeling Techniques
Skin Brightening and Hyperpigmentation
Anti-Aging: Fine Lines & Wrinkles
Anti-Aging: Thinning & Sagging Skin
Acne
Sensitive Skin
I'd like to add modalities and machines
Improve my retail product offerings
I'd like more education
What are you dissatisfied with in your current practice? Please check all that apply.
*
Products I carry are selling cheaper online
Lack of support & help from current supplier
Ineffective peeling, not getting results
Overworking
Ineffective home care products
Cost of products and treatments
Not enough customers
Nothing, I am just looking to add
Current Brand Treatments
*
What professional products are you currently using?
Treatment Experience
Select
None
Less than 1 year
1-2 years
3-5 years
5+ years
On average, how long have you been using their products?
Have you purchased or experienced Dermaesthetics products before?
*
Yes
No
Please list which Dermaesthetics products you have used before.
*
What is the best time to contact you? (Check all that apply)
*
Morning (8 AM - 12 PM)
Afternoon (12 PM - 4 PM)
Evening (4 PM - 8 PM)
Anytime
What is your preferred contact method? (Check all that apply)
*
Call
Text
Email
How do you plan on using Dermaesthetics products?
*
Professional use (to carry in my spa or practice)
Personal use (for my own evaluation or skincare routine)
Both personal and professional use
What area(s) are you interested in?
*
Acne
Anti-Aging
Hyperpigmentation
Education
Other
How did you hear about us?
*
Select
School/Academy
Social Media
Professional Referral
Tradeshow
California Skincare Supply (CSS)
Lincoln Lee
Kristina Pak
Meme Phan
Misha Hwang
Kristine Seganti
Maia Sears
Heidi Corral
Elise Lam
Other
When are you looking to get started?
*
Select
Immediately
Within 1 month
2-3 Months
To be determined
Account Manager
Are you currently working with a DBH Account Manager? If so, please provide a name.
Upload Your Professional License (or current student ID)
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Upload Your ID
*
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Driver's License, Passport, Student ID, etc.
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Upload Your Reseller's Permit (if applicable)
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California residents only
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of
Signature
*
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Lead Source
Brand Importance (read-only)
Desired Timeline (read-only)
Growth Areas (read-only)
Weaknesses (read-only)
Online Retail (read-only)
Previously Purchased (read-only)
Product Usage (read-only)
Product Interest Area (read-only)
Type of Business (read-only)
Referral Source (read-only)
Treatment Experience (read-only)
Lead Source (read-only)
Advanced Registration
Status (read-only)
Need to Verify
Admin Email
example@example.com
Date
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Year
-
Month
Day
Date
Hour Minutes
Time (Initial Submission)
Hour Minutes
AM
PM
AM/PM Option
Time (read-only)
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