2 Week Follow-Up Form Today's Date* MM slash DD slash YYYY Name* First Last Email Address* Home / Cell Phone*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Your progressAre you still breaking out?* Yes No Is your skin getting clearer?* Yes No I am already clear If already clear skip to the product order section of the form.How long have you been on your routine?*How many days per week have you skipped your serum or acne med?*Write out your morning and evening routines step by step.*What products, if any, are burning, stinging or itching?*Are you dry, peeling, flaky and/or red?* Yes No If yes please describe:*Additional comments or questions:Upload PhotosTake 3 photos of your skin and upload them below. NOTE: Before uploading, please rename photos with last name, first name and angle. Ex: smith-mary-leftside.jpg - One from straight on - One from your left side - One from your right side< /br> - Do not use a flashPhotos (max size 128MB each)* Drop files here or Select files Accepted file types: jpg, png, Max. file size: 256 MB, Max. files: 5. Order ProductsWould you like to order products?* Yes No Which products?Please list the products you would like to order here Book Online Buy Gift Certificates Get in touch599 Watervliet Shaker Rd Latham, NY 12110 518-378-4763 email@example.com FollowFollow Located inside Myo Massage.