Intake

Full Name, Title *

Practice Address

Cell Phone

Do you communicate via text message? *

Best Contact Email Address *

Are you currently a Board Certified Dermatologist or Plastic Surgeon? *

If Other, please specify

Specialty *

If Other, please specify

Practice Name *

Corporate Name *

In order to run your STS Injectable Pricing analysis, we need your authorization to obtain and process your account information:

I authorize Skin Type Solutions to pull my account purchase history.

Allergan Account # *

Galderma Account # *

Is there another contact we should be directly communicating with in your practice? If so, please list their name and contact information

Average Number of Patient Visits per Week *

Baseline skincare sales per month *

What is your GOAL for Skincare Sales per Month? *

Please indicate your practice EMR System

Any additional comments

Approximate date to schedule follow-up discussion if not currently scheduled