Name* First NameLast Name Email* ejemplo@ejemplo.com Phone Number* Date of Birth* -Month -DayYear Where do you live?* Other AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Current Date (hidden) -Month -DayYearDate Age Calculation (hidden) We're sorry, we offer out services to people aged 18-65 and we're not yet in CA or NJ. Back Next From a cultural standpoint, how do you identify?* Hispanic, Latino or Spanish originAmerican Indian or Alaskan NativeAsian / Pacific IslanderBlack or African AmericanWhite / Caucasian What language do you speak?* I speak mostly EnglishI speak mostly SpanishI am comfortable with either What gender do you identify with?* WomanManNon-Binary What is your assigned biological sex at birth?* FemaleMaleIntersex Do you have any history of gender affirming surgery (ie. bottom surgery)?* YesNo Are you currently pregnant or breastfeeding, or did you give birth recently, less than 6 weeks ago?* YesNo gender calc (hidden) We're sorry! We cannot offer our treatments to you at this time if you have a history of gender affirming surgery or if you're currently pregnant or gave birth less than 6 weeks ago. We suggest you consult your doctor for this treatment. Back Next Which of the following skin care treatments are you interested in? If you are interested in more than one of these treatments, let us know once you complete the survey.* Acne treatmentWrinkle preventionHyperpigmentation treatment (dark spots) Last question! How did you hear about Cora?* InstagramFacebookFriends and familyGoogleEmailOther MailChimp Tags See plans Should be Empty:
