Reaching the Full Potential of Rosacea Healing

Rosacea-Ltd IV Assistance Form

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

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.

File date or "Date on your Letter of Instruction.
Please use this format ##/##/####

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 0 to 10 please rate the appearance of existing rosacea affected skin area after the use of Rosacea-Ltd IV:

4. Are your acne pimples and pustules less visible?
    0 1 2 3 4 5 6 7 8 9 10
5. Do you have less rosacea papules which are "small hard elevated red lesions (red areas) without pus"?
    0 1 2 3 4 5 6 7 8 9 10
6. Do you see "less surface area" of reddish skin or less inflammation?
    0 1 2 3 4 5 6 7 8 9 10
7. Do you feel "less intensity of redness" since you began?
    0 1 2 3 4 5 6 7 8 9 10
8. Do you see less symptoms in your ocular rosacea?
    0 1 2 3 4 5 6 7 8 9 10

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? Alkaline water has a pH between 7.0 and 7.3. Please review on our
Rosacea's Cause and Cure page.

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.

3. Are you using a wash cloth 3 times per day (upon arising, after work and at bedtime) as recommended in your Letter of Instruction?
Yes No

4. Are you using the Jojoba oil or Safflower oil as recommended?
Yes No

5. Are you using a retinoid, wrinkle remover to exfoliant the skin, or any other medication, non-prescription or any cosmetic product?
Yes No
If yes, which one?

6. How many hours each day do you average being in the sun? And are you using CityBlock by Clinique (SPF 40) provide the most blockage and the least irritation and sensitivity. CityBlock can be purchased online and in the skin care department in stores worldwide as recommended on our web site?

7. Have you had photoderm/laser surgery, used Accutane, Benzolyn peroxide, or any topical or oral medications?
Yes No
If yes, which one?

8. Please answer each individual question as follows. How many cups of the following do you drink?
Soft Drinks:

9. Are you applying a two second or less application of Rosacea-Ltd IV to each side of your face? And remember that "Less is More" and that Rosacea-Ltd IV penetrates and migrates and the entire affected area does not need an application.
Yes No

10. What is your normal or average urine pH as taken twice a day with pH strips? This is to be completed before you start using Rosacea-Ltd IV as you read on our Rosacea's Cause & Cure Page. or enter 0 (zero) if you don't know.

11. On which date did you start the applying Rosacea-Ltd IV to your skin?

12. 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.

Please type in the numbers below:


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