• Online Acne Consultation

    For Clients Who Are Not Local To Our Physical Office In Cary NC

  • STEP ONE:

    Take Photos of Your Skin Before Taking the Quiz!


    Pictures taken with a smartphone are fine; you will need to upload them to this intake form at the end of the questionnaire. 

     Instructions for taking photos

    -Do not use flash

    -Make sure that your pictures are not fuzzy or blurry

    -Take four photos

    -One from each side

    -One straight on

    -Two of your most problematic areas 

  •  -

  • Prescribed and Over the Counter Medications (Past and Present Use)

  • Are you currently pregnant? *
  • Are you currently nursing? *

  • Current Skin Care Regimen

  • Have you ever had bad or allergic reaction to anything you have ever put on your face? *
  • Check if you are allergic to:*
  • What  are your skin care concerns?*

  • What is your general Skin Type? *

  • Lifestyle Questions

  • Check box if Yes:
  • Do you use Fabric Softener or Dryer Sheets?*
  • Do you regularly eat or ingest:*

  • Time to Submit Photos

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  • PAYMENT *

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    Online Consultation Fee. **Originally $50- on sale for Cyber Monday** We will contact you after we receive payment to schedule a zoom call for Acne Coaching Intake and begin your program.

    Total $0.00$0.00

    Payment Methods

    creditcard
    After submitting the form, you will be redirected to Apple Pay to complete the payment.
    After submitting the form, you will be redirected to Google Pay to complete the payment.
    After submitting the form, you will be redirected to Cash App Pay to complete the payment.

  • **Important. Please Read First**

    After submitting the form, an invoice will be sent to the email address you provided above. The consultation process will begin once payment has been made. We will call to schedule within 24 hours.

     

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