Do you qualify for the Tanning & Sexual Health Protocol?
What is your gender?
*
Male
Female
Are you currently pregnant or breastfeeding?
*
Yes
No
Do you have any allergies or sensitivities to products that contain copper?
*
Yes
No
Do you have Wilson's Disease?
*
Yes
No
Do you use Vitamin A or any other retinoid compounds, Vitamin C, tretinoin, any alpha hydroxy acids (AHAs) in your current skin care routine?
*
Bloating
Stomach pain/cramps
Irregular bowel movements
Constipation
Diarrhea
Nausea
Heartburn/reflux
None of the above
Do you take any prescription or over the counter medications to treat acne or hair loss?
*
Yes
No
Please list your prescriptions and medications below:
First Name
Last Name
Date of birth
Phone
Email
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