Skin Condition Medical Show
Applicant Questionnaire
Email address *
First Name *
Last Name *
Age *
Phone *
City, State *
Link to your Facebook or Instagram page
(please COPY AND PASTE the full link from 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? *
(insurance is not required to be considered as a candidate)
If you are selected to participate, filming would occur sometime between March 30 - April 10. Do you have any conflicts that would prevent you from being available on those dates? *
Do you have one or two photos of your condition available to email? *
If "yes," please email them - and a current selfie - to with your full name in the subject line (max size 9 MB)
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