Rosacea-Ltd IV Assistance Form


                         

The purpose of the Rosacea-Ltd IV Assistance Form for existing Rosacea-Ltd IV patients only:

1) PRIOR to the start of Rosacea-Ltd IV as you might have questions or concerns of your future use of Rosacea-Ltd IV or existing problem prior to the start of Rosacea-Ltd IV.

To assist you in improving the appearance and condition of your rosacea, acne or seborrheic-dermatitis skin condition, please complete all blanks below. Optional information (up to a full page of your comments) is welcome in the comment section.

Please be precise so we can assist you. We need to know what you have been doing, and what you have "NOT" been doing'. You are not limited to the boxes below as they will continue for several paragraphs if needed.

 

Name:  

File date or "date on your Letter of Instructions".  


Email address:   


1. How many years do you think that you have had rosacea?

2. How many years have you seen a dermatologist for rosacea?

3. What medication have you most recently used "just prior" to using Rosacea-Ltd IV? And which other in the past?


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

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 acne pimples and pustules less visible?

5.Do you have less rosacea papules which are "small hard elevated red lesions (red areas) without pus"?

6. Do you see "less surface area" of reddish skin or less inflammation?

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

8. Would you have any other thoughts in conjunction with 1 through 7 above that could further identify any problem areas that need to be resolved.

    You may write several pages as size is not restricted.

   


Also, please include your answers to the following so we may assist you further. To read our recommendations, please click on the links.
  1. The number of glasses of "alkaline water" you are drinking each day. How many should I?

  2. The soap you are using to clean your face and if the brand offers more than one soap, give us the exact one so we can confirm that you are using the proper one. What is a good soap?

  3. Are you using a wash cloth 3 times per day (upon arising, after work & at bedtime?) Yes     No     What is recommended?

  4. Are you using the Jojoba oil? Yes     No     What does Jojoba oil do?

  5. Are you using a retinoid, wrinkle remover to exfoliant the skin? Yes     No
    If yes, which one? What should be avoided?

  6. How many hours each day do you average being in the sun? How many is best?

  7. Have you had photoderm/laser surgery, used Accutane, or any topical or oral medications? Yes     No
    If yes, which one? What is the effect of laser treatment?

  8. Please state for each individual question as follows: How many cups of coffee? How many cups/glasses of tea; How many sodas (pops or soft drinks), beer, wine or alcohol or other 'acid drinks' are you consuming each day? What do they do?

  9. Are you applying a two second or less application of Rosacea-Ltd IV to each side of your face? Yes     No     How should Rosacea-Ltd IV be applied?

  10. What is your normal or average urine pH as taken twice a day with pH strips?


  11. Have you started the use of Rosacea-Ltd IV? Or if you have started the Rosacea-Ltd IV application, on which date (or approximately) did you start the application process? Also there is plenty of space for any other thought or question as space is "not limited to the visual box" so you can write several sentences or paragraphs as needed to further explain or ask other questions or concerns if needed.

© 1998-2002    Bass and Boney, Inc.

 

  Rosacea-Ltd IV has a 120 day, 100 percent refund for any reason.