Skin Analysis

Welcome to the Med3 Dermaceuticals Skin Analysis Page. We really care about how you use our products and would like to learn more about your skin type.

By filling out this form for us, we will return to you a personalized skin care regimen, and a free sample of Collagen Treatment. (One time offer).

So go ahead, send this form to us and start out on your new quest for Healthy Radiant Skin At Any Age!!!

Name
Address
Address 2
City
State	-- AK AL AR AS AZ CA CO CT DC DE FL GA GU HI IA ID IL IN KS KY LA MA MD ME MH MI MN MO MP MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR PW RI SC SD TN TT TX UT VA VI VT WA WI WV WY YT BC AB SK MB ON NB QC NS NF
Zip
Email
How did you hear about us?
Age:	-- 18-25 26-40 41-55 56-70 70+
Skin Tone	-- Very Fair – Blonde or Redhead Freckles, Burns easily Fair - Blonde, burn turns to tan Medium - Light brown hair, hazel eyes, sometimes burn Olive - Darker skin, Hispanic or Asian, rarely burns Dark - Dark hair and eyes, African-American, rarely burn
Skin Type	-- Very Oily Oily Dry Combination Normal
Do you:	Exercise regularly Sleep well Eat healthy Spend time outdoors Use sunblock Spend time with friends Laugh Smoke Drink alcohol Have allergies
Do you use:	Retin A Accutane Birth Control Diet Drugs Caffeine Tanning Booths
Are you pregnant or trying to get pregnant?	Yes No
Do you wear glasses?	Yes No
Your Skin Quality:
Fine Lines	Yes No Some
Deep wrinkles	Yes No Some
Dry skin	Yes No Some
Age Spots	Yes No Some
Puffiness around the eyes	Yes No Some
Dark circles under the eyes	Yes No Some
Large pores	Yes No Some
Small pores	Yes No Some
Thin skin	Yes No Some
Uneven skin tone	Yes No Some
Oily skin	Yes No Some
Blackheads	Yes No Some
What skin care line do you use now?
Please describe briefly your biggest skin care concerns:
What are you looking for most in a skin care line?