• Virtual Consultation Purchase

    This form is your online consultation and may take you 10-15 minutes to fill out. You will need to know the exact names on your skincare and makeup products or have photos of them to upload. You will also be asked to upload photos of your skin in natural light. You will pay for your Virtual Consultation & Acne Kit on the last page. Payments are securely processed through Square and you will receive a receipt upon submission. Once I've received your form, I will be in touch within 2 business days.
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  • Date of Birth*
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    2 digit month, 2 digit day, 4 digit year

  • Skin History

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  • SKIN TYPE (select all that apply)*
  • SKIN SENSITIVITY LEVEL: You are likely sensitive in that your skin breaks out easily. To help me determine your skin’s sensitivity to products, please describe how sensitive you believe your skin to be when it comes to how tingly products with active ingredients feel on your skin.*
  • Browse Files
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  • Current Products & Skin Routine

    Please give EXACT names of products OR upload a photo of it below. (Bonus points for pictures with the ingredient label if available.)
  • Browse Files
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  • Morning Routine (please share however many steps you do and write the name of the product you use.). If you only cleanse with water or do nothing, please write "water" or "nothing":

    1. Cleanse with:
    2.       
    3.    
    4.   
    5.  

       

  • Night Routine:

    1. Cleanse with:
    2.       
    3.    
    4.   
    5.  

       

  • MAKEUP: Please give exact name or upload a photo. Lipstick and eye makeup do not need to be included. Skip if you do not wear makeup.

    Primer:   
    Foundation / Tinted Moisturizer:
    Concealer:      
    Powder:   
    Blush:  
    Bronzer:   
    Contouring / Highlighter: 
    Other face makeup:
       

  • HAIR PRODUCTS: Do you use hair products with coconut oil, argan oil, moroccan oil or shea butter?
  • Do you use a Clarisonic or other facial brush?
  • ACNE PRESCRIPTIONS Please mark all acne treatments you have tried in the PAST:*

  • MEDICAL HISTORY: Have you been diagnosed with any of the following?*
  • MEDICATIONS: Do you take any of the following medications?*
  • Are you pregnant, nursing or trying to conceive?*
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  • Do you pick at your skin?*
  • Do you use fabric softener or dryer sheets?*
  • Do you smoke?*
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  • Client Agreement

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  • Getting clear skin is a process that takes time and effort. Your acne did not develop overnight and it will take 3-4 months (or sometimes 6 months for severe non-inflamed acne) to clear. Along with your new products, you will receive an acne packet that outlines acne aggravators and provides helpful tips for clear skin. I am here to coach you along the way, but the majority of the work is up to you. 

    If you are ready to get started, please agree to the following and complete the last step of payment. You will receive a "Thank You" message and email receipt once your form is submitted. 

    I am excited to work with you!

    -Deborah

  • Please mark ALL of the following and sign below.*

  • Payment

    Page 6 of 6.

  • You are purchasing the following:

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    Online Acne Consultation & Acne Kit. Kit include the cost of six full sized Face Reality products to get you started on your new skincare routine: cleanser, moisturizer, spf, serum, treatment gel, toner. Your kit will be unique for your personal skincare needs, acne type and sensitivity level.



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