Skip to content
Laser Resurfacing Survey
Fill this Survey to get $100 discount on your Fraxel Laser session
*
1.
Have you had Laser skin resurfacing before?
(Required.)
Yes
No
2.
If yes, what was the procedure you had?
Fraxel Laser
Fractional Radio frequency Microneedling (Infini)
Chemical Peel
Carbon Peel
Other (please specify)
*
3.
What is the main skin issue you have now?
(Required.)
Acne Scars
Pigmentation
Skin texture
stretch marks
Other (please specify)
4.
Overall, how satisfied or dissatisfied were you with the results
Very satisfied
Satisfied
Neither satisfied nor dissatisfied
Dissatisfied
Very dissatisfied
5.
Do you use Sunblock on daily basis?
Yes
No
6.
Do you take a medication that makes your skin sensitive to sun light?
Yes
No
I am not sure
7.
Can you afford to stay at home for three days after the procedure?
Yes
No
I am not sure
*
8.
How did you hear about us?
(Required.)
Google search
Facebook ad
Instagram ad
Printed media
Word of mouth
*
9.
Please provide us with your information
(Required.)
First name
Last name
Email Address
Phone Number
*
10.
How do you like us to contact you?
(Required.)
Phone call
Email
Text message
