Research Participant Form

BAUMANN COSMETIC AND RESEARCH INSTITUTE STUDY PARTICIPANT INFORMATION SHEET

If you are interested in participating in future research studies, fill out this form and you will be contacted when we have a study that fits your interests. ( * Fields marked with an asterisk below are required. )

* Last Name:

* First Name:

* Gender: Male Female

* Date of Birth:

Place of Birth (City/State or Country of origin):

Street Address:

City:
State:
Zip Code:

Home Phone:
Mobile Phone:
Work Phone:
Pager:

* Email:

Please enter where you prefer to be contacted:

Please select your racial or ethnic group:

Language preference:

* When exposed to the sun for an hour or more without any sun-screen protection, select the skin type that describes what happens to you:

* Select your natural hair color:

* Select your natural eye color:

Please select from this list the types of studies in which you would be interested in participating (Mark all that are of interest to you):

Acne
Cellulite
Glabellar wrinkles(frowning lines between the eyebrows) Hyperhidrosis palmar(excessive sweating of the palms) Laser hair removal
Marionette lines(lines at the corners of the mouth that extend into the chin area) Photoaging(sun damage) Seborrheic keratoses(moles, other skin lesions) Shaving irritation
Spider veins of the legs

Acne scars
Crow's feet wrinkles
Forehead wrinkles
Hair removal
Keloid scar
Lip augmentation
Neck wrinkles
Abnormal pigmentation
Skin care
Striae(purple, red, pink or white stretch marks)

Aging prevention
Chest wrinkles
Freckles
Hyperhidrosis axillary(excessive underarm sweating) Laser
Melasma(tan or dark skin discoloration) Nasolabial folds(lines that extend from the corners of the nose downwards to the corners of the mouth) Rosacea(facial redness) Spider veins of the face
Undereye circles

Enter other area of interest:

* By signing my name in this box, I agree to be contacted for future research studies.
This authorization does not have an expiration date:

You may revoke (take back) this authorization at any time and for any reason. To do so, you must write to:

Leslie Baumann, MD
Baumann Cosmetic and Research Institute
4500 Biscayne Blvd. Suite 105
Miami, FL 33137
Tel (305) 531-5788
Fax (305) 531-5789