Pigmentation treatment Survey Fill this Survey to get $100 discount on your pigmentation treatment Question Title * 1. What is your gender? Female Male Rather not answer this question OK Question Title * 2. What kind of pigmentation do you have? Birthmark Melasma Sun burn Freckles or Liver spots After Laser or tanning Not sure, please describe it in your own words OK Question Title * 3. Where is the pigmentation? Face hands Other (please specify) OK Question Title * 4. At which age did you first notice pigmentation on your skin? Since birth Under the age of 20 Between ages 20-30 Between ages 31-40 Over 41 OK Question Title * 5. Did you pigmentation appeared after a special occasion such as pregnancy or cosmetic treatment No Yes, please specify OK Question Title * 6. Let us determine your skin Fitzpatrick score? always burns, never tans (pale white; blond or red hair; blue eyes; freckles) usually burns, tans minimally (white; fair; blond or red hair; blue, green, or hazel eyes) sometimes mild burn, tans uniformly (cream white; fair with any hair or eye color) burns minimally, always tans well (moderate brown) very rarely burns, tans very easily (dark brown) Never burns, never tans (deeply pigmented dark brown to darkest brown) OK Question Title * 7. Have you had treatment for it before? No Yes (please specify) OK Question Title * 8. Have you had a laser treatment have you had before? No Laser hair removal Fractional laser (such as Fraxel) for skin tightening Short pulse laser for pigmentation or tatoo removal Vein removal Other (please specify) OK Question Title * 9. In your opinion, how safe is laser treatment in general? Extremely safe Very safe Somewhat safe Not so safe Not at all safe OK Question Title * 10. If you had laser treatment before, how satisfied or dissatisfied were you with the results Very satisfied Satisfied Neither satisfied nor dissatisfied Dissatisfied Very dissatisfied OK Question Title * 11. What is the most important consideration when choosing a cosmetic clinic or spa Reputation The brand of the Laser machine Prices and promotions Location and parking Social media profiles Other (please specify) OK Question Title * 12. How did you hear about us? Google search Facebook ad Instagram ad Printed media Word of mouth OK Question Title * 13. When are you planning to do the laser procedure Less than two weeks More than two weeks OK Question Title * 14. Please provide us with your information First name Last name Email Address Phone Number OK Question Title * 15. How do you like us to contact you? Phone call Email Text message OK DONE
