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

Month Day Year

Full Name

First Name Last Name

Age

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone

Area Code Phone Number

Cell Phone

Area Code Phone Number

E-mail

How did you hear about us?

ALLERGIES (please list ALL)

Current skin care regimen

Cleanser

Yes No

Brand, Type, How Often

Day Moisturizer

Yes No

Brand, Type, How Often

Night Moisturizer

Yes No

Brand, Type, How Often

Retin A, Renova

Yes No

Brand, Type, How Often

Alpha Hydroxy Acid

Yes No

Brand, Type, How Often

Make up

Yes No

Brand, Type, How Often

SPF

Yes No

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?

Yes No

Reason for visit

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

Yes No

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

Are there any medical problems we should be aware of?

Yes No

If so, please list

When tanning, do you burn easily

Yes No

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

Yes No

List antibiotics

In the past five years have you had or used?

Accutane

Yes No

Acne

Yes No

Dermatitis/Eczema

Yes No

Glycolic Acids

Yes No

Keloid Scars

Yes No

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

Yes No

Do you have problems with healing or scarring?

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

1-4 Hours 5-10 Hours 11-15 Hours 16+ Hours

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

I do not use indoor tanning beds less than 20 Minutes 20 Minutes - 1 Hour 1-2 Hours 2+ Hours

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

Yes No

When

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

Yes No

When

What is your skin complexion?

Light Medium Olive Dark

Is your skin

Dry Oily Combination Acne Prone

Other:

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

Fitzpatrick I Always burn, never tan Fitzpatrick II Always burn, sometimes tans Fitzpatrick III Sometimes burns, always tans Fitzpatrick IV Always tan, never burns Fitzpatrick 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