Pigmentation treatment Survey

Fill this Survey to get $100 discount on your pigmentation treatment

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1. What is your gender?

Female

Male

Rather not answer this question

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2. What kind of pigmentation do you have? (Required.)

Birthmark

Melasma

Sun burn

Freckles or Liver spots

After Laser or tanning

Not sure, please describe it in your own words

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3. Where is the pigmentation? (Required.)

Face

hands

Other (please specify)

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4. At which age did you first notice pigmentation on your skin? (Required.)

Since birth

Under the age of 20

Between ages 20-30

Between ages 31-40

Over 41

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5. Did you pigmentation appeared after a special occasion such as pregnancy or cosmetic treatment

Yes, please specify

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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)

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7. Have you had treatment for it before? (Required.)

Yes (please specify)

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8. Have you had a laser treatment have you had before?

Laser hair removal

Fractional laser (such as Fraxel) for skin tightening

Short pulse laser for pigmentation or tatoo removal

Vein removal

Other (please specify)

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9. In your opinion, how safe is laser treatment in general? (Required.)

Extremely safe

Very safe

Somewhat safe

Not so safe

Not at all safe

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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

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11. What is the most important consideration when choosing a cosmetic clinic or spa (Required.)

Reputation

The brand of the Laser machine

Prices and promotions

Location and parking

Social media profiles

Other (please specify)

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12. How did you hear about us? (Required.)

Google search

Facebook ad

Instagram ad

Printed media

Word of mouth

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13. When are you planning to do the laser procedure (Required.)

Less than two weeks

More than two weeks

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14. Please provide us with your information (Required.)

First name

Last name

Email Address

Phone Number

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15. How do you like us to contact you? (Required.)

Phone call

Text message

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* 1. What is your gender?

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* 2. What kind of pigmentation do you have? (Required.)

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* 3. Where is the pigmentation? (Required.)

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* 4. At which age did you first notice pigmentation on your skin? (Required.)

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* 5. Did you pigmentation appeared after a special occasion such as pregnancy or cosmetic treatment

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* 6. Let us determine your skin Fitzpatrick score?

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* 7. Have you had treatment for it before? (Required.)

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* 8. Have you had a laser treatment have you had before?

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* 9. In your opinion, how safe is laser treatment in general? (Required.)

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* 10. If you had laser treatment before, how satisfied or dissatisfied were you with the results

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* 11. What is the most important consideration when choosing a cosmetic clinic or spa (Required.)

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* 12. How did you hear about us? (Required.)

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* 13. When are you planning to do the laser procedure (Required.)

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* 14. Please provide us with your information (Required.)

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* 15. How do you like us to contact you? (Required.)

1. What is your gender?

2. What kind of pigmentation do you have? (Required.)

3. Where is the pigmentation? (Required.)

4. At which age did you first notice pigmentation on your skin? (Required.)

5. Did you pigmentation appeared after a special occasion such as pregnancy or cosmetic treatment

6. Let us determine your skin Fitzpatrick score?

7. Have you had treatment for it before? (Required.)

8. Have you had a laser treatment have you had before?

9. In your opinion, how safe is laser treatment in general? (Required.)

10. If you had laser treatment before, how satisfied or dissatisfied were you with the results

11. What is the most important consideration when choosing a cosmetic clinic or spa (Required.)

12. How did you hear about us? (Required.)

13. When are you planning to do the laser procedure (Required.)

14. Please provide us with your information (Required.)

15. How do you like us to contact you? (Required.)