Voluntary Skin Care Evaluation Form

Thank you for your interest in trying our new product line! Please complete this form if you would like to be entered into the general database for product trial and feedback being conducted now or in the future. By completing this form in no way obligates you to participate. You may modify or withdraw your information at any time by contacting us (843-379-2284).

Bathe is seeking men and women of all ages! Product testers will try products for a period of time and provide feedback. Our current testing opportunity is for our new facial skin care line, Bathe Your Face. The information you provide will be made available to Bathe employees. If selected to participate, you will be contacted via email with further instructions.

PLEASE NOTE: This is not a clinical trial. All information entered is completely voluntary. Applicants do not need to complete all questions to be registered to participate. The information submitted will be used to guide Bathe employees to select the best product(s) for your skin type. Bathe cannot guarantee the safety and security of the information you submit.

Personal Information

Todays Date

MonthDayYear

Full Name

First NameLast Name

Age

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Home Phone

Area CodePhone Number

Cell Phone

Area CodePhone Number

E-mail

How did you hear about us?

ALLERGIES (please list ALL)

Current skin care regimen

Cleanser

YesNo

Brand, Type, How Often

Day Moisturizer

YesNo

Brand, Type, How Often

Night Moisturizer

YesNo

Brand, Type, How Often

Retin A, Renova

YesNo

Brand, Type, How Often

Alpha Hydroxy Acid

YesNo

Brand, Type, How Often

Make up

YesNo

Brand, Type, How Often

SPF

YesNo

Brand, Type, How Often

Please describe any adverse reaction from a skin care product, cosmetic or skin care treatment experienced within the 24 months

Have you seen a dermotologist in the past five years?

YesNo

Reason for visit

Have you taken Accutane for acne in the past three months:

YesNo

Do you have any existing skin conditions? Check all that apply.

Are there any medical problems we should be aware of?

YesNo

If so, please list

When tanning, do you burn easily

YesNo

Do you use oral or topical antibiotics to treat skin problems?

YesNo

List antibiotics

In the past five years have you had or used?

Accutane

YesNo

Acne

YesNo

Dermatitis/Eczema

YesNo

Glycolic Acids

YesNo

Keloid Scars

YesNo

Products containing Alpha Hydroxy Acids (other than Glycolic Acid)?

YesNo

Do you have problems with healing or scarring?

How often are you exposed to the sun per week (average)

1-4 Hours5-10 Hours11-15 Hours16+ Hours

How often are you exposed to indoor tanning beds per week (average)

Have you recently vacationed or are you planning a vacation with sun exposure within the next 3 months?

YesNo

When

Have you recently or are you planning to use sunless tanning products within the next 3 months?

YesNo

When

What is your skin complexion?

LightMediumOliveDark

Is your skin

DryOilyCombinationAcne Prone

Other:

Check the number that best describes your skin's response to sun exposure without SPF protection?

Fitzpatrick I Always burn, never tanFitzpatrick II Always burn, sometimes tansFitzpatrick III Sometimes burns, always tansFitzpatrick IV Always tan, never burnsFitzpatrick V Medium to dark skin (Asian, Hispanic, Indian, etc)FitzpatrickVI Black skin

What do you want to improve most about your skin?

BATHE SKIN CARE PRODUCT FEEDBACK