Submit Profile Joan Hankel, R.N. and Medical Esthetic Specialist When you submit the following facial profile, you are letting us know that you are interested in learning more about the ABY! Skin Care System and how it can benefit you or someone you know.  I, or one of my trained consultants, will provide you with a no-cost, no-hassle telephone consultation.  Thereafter, if you wish to begin using ABY! products, we will determine what program is best for you, based in part on the information you provide below.  There is no obligation to purchase. Call today for your free consultation.  Our hours are 9:30 a.m. to 5:30 p.m., Pacific Time.  First Name Last Name Address Line 1 Address Line 2 City State Zip Code Country Home Telephone (Mandatory so we can reach you for your free consultation) () - Work Telephone (If okay to contact you there during business hours) () - E-mail Address Medications you are taking: List any allergies to medications: Do you have any serious illnesses? If so, please specify: Are you currently pregnant or trying to become pregnant? List any of the following products you have used or are currently using: Retin-A, Differin, Tazorac, oral or topical antibiotics, other: How recently did you use these products? How consistently did you use any of these products (e.g., daily for a year, etc.)? How long has it been since you have used benzoyl peroxide? IMPORTANT! Have you had any side effects from any of these products: Benzoyl peroxide, Pro Active, Benzamycin, Benzaclin, Clearsil, Oxy 5 or 10? If so, please list and describe symptoms: Did you experience severe irritation, dryness, rash, itching or swelling? (Note: This information is extremely important in determining the strength of program you should be able to use.) Have you ever taken acutane? If so, how long ago, and did you experience any side effects: Have you ever used sulfur? If so, how long ago, and did you experience any side effects? What is your ethnic background? How would you describe your skin type (e.g., sensitive, dry, oily)? When do you become oily (e.g., immediately after cleansing, mid-day, etc.)? What areas of your face are most oily? Do you have blackheads or whiteheads? Do you have cysts or milia? What else can you tell us about you and how you want to improve your skin? Do you have dark spots or white spots? If applicable, do you have any problem with in-grown facial hair, razor burn or skin irritation when shaving? Please describe: Comments CAUTION! Improper use of this program may result in temporary redness, swelling, burning, itching, and extreme dryness and peeling.  ABY! Skin Care will not assume responsibility for improper use of, or any allergies to, any of these products.