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Skin Condition Medical Show
Applicant Questionnaire
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* Required
Email
*
Your email
First Name
*
Your answer
Last Name
*
Your answer
Age
*
Your answer
Phone
*
Your answer
City, State
*
Your answer
Link to your Facebook or Instagram page
(please COPY AND PASTE the full link from your Facebook or Instagram page)
Your answer
Briefly describe your skin condition
*
Your answer
How long have you had this condition?
*
Your answer
Why have you not taken care of the condition already? (Money? Fear? Overwhelmed? etc.)
*
Your answer
Have you had the condition professionally diagnosed, or have you done your own research?
*
Your answer
Briefly describe how the condition is negatively affecting you. Please be specific (pain or mobility issues? low self esteem? has it affected relationships or your professional life?)
*
Your answer
Do you have any other health problems? Cardiac issues, blood-borne infections, diabetes, auto-immune diseases? Are you on blood thinners or any other prescription medication? (please list conditions and medications)
*
Your answer
Do you currently have health insurance?
*
(insurance is not required to be considered as a candidate)
Yes
No
If you answered "Yes" to having health insurance, please let us know who it's through and what kind. (Blue Cross PPO, United HMO, Medicare, Medicaid, etc.)
(insurance is not required to be considered as a candidate)
Your answer
If you are selected to participate, filming would occur sometime between January 4 - March 29. Do you have any conflicts that would prevent you from being available on those dates? (All production will adhere to state and local COVID guidelines, so a quarantine period up to two weeks may be required before any medical procedures are performed)
*
Yes
No
How did you hear about this casting?
Your answer
Do you have one or two photos of your condition available to email?
*
If "yes," please email them - and a current selfie - to
casting@alexshaw.tv
with your full name in the subject line (max size 9 MB)
Yes
No
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