Face Reality Skincare Bootcamp

Face Reality Acne Bootcamp

Please fill out the form below and I will get back to you within 72 hours so we can take the next steps. I look forward to helping you finally achieve clear skin! Your privacy is very important. The following information is only used to assess your skin care goals, determine what treatments are appropriate for your skin condition and to avoid any possible reactions.
Date*

MonthDayYear
Full Name*

First Last
Age*
Birthdate:*
ex. 01/05/1960
E-mail*
We will never SPAM or sell email addresses to third parties.
Phone:*
ex. 555-555-5555
What is the best way to contact you?*
How did you hear about us?*
If you were referred, please let us know who from
If other, please let us know
How severe is your acne?*

Mild (10 lesions or less on each side of face)Moderate (10 to 30 lesions on each side of face)Severe (30 or more lesions on each side of face)
Is your skin...*

Inflamed (pimples, pustules or cyst)Non inflamed (Blackheads and whiteheads)Combination
Is your skin typically...*

DryOilyCombinationNormalI don't know
How long have you been struggling with acne? *
Tell me your acne journey*
Are you currently or have you previously seen a dermatologist regarding your acne?*

YES - currentlyYES - previouslyNO
If yes, did dermatologist prescribe any prescription (topical or oral)? If so, please list them*
Have you previously had any skin treatments? If yes, what treatments have you done?*
What have you tried in an attempt to clear your skin?*
Do you have a skincare routine?*

NOYES
If yes, what is your current skincare routine?*
Do you have any known allergies, medical conditions or sensitives*

NOYES
If yes, please list them*
Are you currently pregnant or breastfeeding?*

NOYES
Are you currently on birth control? If yes, please list type of birth control*
Have you watched the Face Reality Philosophy video on the website?*

NOYES
The Virtual Acne Program is designed to clear skin without the use of prescription acne medications. Are you willing to discontinue prescription acne medications, antibiotics, creams, and drugstore products before starting the program?*

NOYESMAYBE
Lifestyle adjustments are a very important component of the Virtual Acne Program, and may include changes to your daily habits, diet, beauty products, and other areas of your life. Are you willing to make these changes in order to achieve and maintain clear skin long-term?*

NOYESMAYBE
The Virtual Acne Program is a financial investment, but clients also need to invest their time, energy, and a positive mindset into the program for best results. Are you willing to invest in the program financially, mentally, and emotionally?*

NOYESMAYBE
Most acne clients achieve clear skin in 4 to 6 months, but this timeline varies based on your type and severity of acne, willingness to implement lifestyle adjustments, and overall commitment to the Virtual Acne Program. Are you willing to be patient, understand that your acne may take several months to clear, and also understand that maintaining clear skin is a long-term process?*

NOYESMAYBE
Which Face Reality Bootcamp Program are you interested in?*

In-personVirtual
On a scale of 1-10 how committed are you to achieving clear skin? *
Please upload photos of your skin without makeup (front, left side and right side)*

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Anything else you'd like to share with me?*
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I am aware that it is my responsibility to inform the esthetician of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release Skin Clinical and/or the skin care professional from liability and assume full responsibility thereof.*
Client Signature:*

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Face Reality Acne Bootcamp