First Name *

Last Name *

Age *

Phone *

City, State *

Link to your Facebook or Instagram page

Briefly describe your skin condition *

How long have you had this condition? *

Why have you not taken care of the condition already? (Money? Fear? Overwhelmed? etc.) *

Have you had the condition professionally diagnosed, or have you done your own research? *

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?) *

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) *

Do you currently have health insurance? *

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.)

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) *

How did you hear about this casting?

Do you have one or two photos of your condition available to email? *