Assistance Form

To assist you in improving the appearance and condition of your seborrheic dermatitis, eczema, or psoriasis skin condition, please complete "all blanks" below. Optional information (up to a full page of your comments) is welcome in the comment section. If you click on the SEND button and are told that your Assistance Form is not complete, press the BACK button on your browser and check for any incomplete form fields.

 

Name:  

File date or order 'date' on personalized letter to you:  


Email address:   


1. How many years do you think that you have had dermatitis, eczema, or psoriasis?

2. How many years have you seen a dermatologist for your skin condition?

3. What medication have you most recently used "prior" to using Dermatitis-Ltd III?


On a scale of 1 to 10 please rate the appearance of existing affected skin area after the use of Dermatitis-Ltd III:

No noticeable change
over prior product

Significant improvement
over prior product

  0

  1

   2

 3

 4

 5

 6

 7

  8

  9

 10

4. Are your affected areas less noticeable?

5. Is any inflammation less visible?

6. Do you see less surface area of reddish flaky skin color?

7. Do you feel less intensity of redness and flakiness since you began?



Also, please include your answers to the following so we may assist you further.
  1. How many glasses of water are you drinking each day?

  2. The cleanser you are using to clean your face and if the brand offers more than one cleanser, give us the exact one.

  3. Are you using the Jojoba oil? Yes     No

  4. Are you getting 8 hours of sleep per night? Yes     No
    And more on weekends? Yes     No

  5. Any other thoughts or unusual considerations that you would like to tell us or ask us.

© 1998-2013    Bass and Boney, Inc.

 

  Dermatitis-Ltd III has a 120 day, 100 percent refund for any reason.