AK Therapy Skin Check In Survey. Win $50

Do you have "sun spots"?	Yes No *
Have you ever been diagnosed with "actinic keratoses" (AKs)?	Yes No *
If so, when?
Have you ever had your AKs:	Surgically removed Treated with topical medication
If you were treated with a topical medication, what was the product name?
Were you satisfied with your treatment?	Yes No
Would you like to receive information about an innovative therapy for AKs that can be completed right in your doctor's office with little downtime?	Yes No

First Name:	*
Last Name:	*
Date of Birth (MM/DD/YY):	*
Street Address:	*
City:	*
State:	*
Zip Code:	*
Phone Number:	*
E-mail:	*
Please enter the anti spam code: (case-sensitive)
	* = Required Field

We would like to get to know you a little better!