Name
Phone
Email Address
Where/how did you hear About Merwin's pharmacy?
Tell us about your SCar
What is the scar from?
How old is your scar?
What does your scar look like? Please be very descriptive.
Do any of the following describe your scar?
Raised
Red
Itch
Hard
Where is your scar located?
How large is your scar?
Is your scar painful?
Yes
No
Has your scar been previously treated? (include over-the-counter products, i.e. Mederma)
Yes
No
If yes, please list all therapies:
Who is your practitioner (in case a prescription is needed)?
Practitioner's phone:
Practitioner's address (include city, state & zip):
Thank you!
SCAR ASSESSMENT
Would you like to receive emails regarding events/promotions? We do not share your information.
Yes
No
Date of Birth