Acne Intake Form
Thank you for reaching out to Live by Skin for your acne needs! Please complete this form so we can make the most of your consultation!
Full Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Date of Birth
*
/
Month
/
Day
Year
Date
Health History
Medications
*
Antibiotics
Accutane
Benzoyl Peroxide
Retin-A
Tazorac
Differin
Azelex
Avita
Cleocin-T
E-mycin-T
Copaxone
Corticosteroids
Quinine
Androstendione
Testosterone
Progesterone
Thyroid
Gonadotrophin
Danzol
Cyclosporin
Lithium
Isoniazid
Immuran
Disulfuram
Dilantin/Tegretol
Steroids
Marijuana
Cocaine/Speed
Other
Medical History (Check all that apply)
*
Herpes-Simplex
Eczema
Psoriasis
Hepatitis
Cancer
Staph Infection/MRSA
HIV/AIDS
Thyroid Problems
Hormone Problems
Hysterectomy
Ovary(ies) Removed
Pacemaker
Hemophilia
Lupus
Anemia
High Blood Pressure
Diabetes
Metal Pins in Body
Other
Are you under a dermatologist's or other specailist's care?
*
Yes
No
Have you ever had a cold sore?
*
Yes
No
Lifestyle Considerations
Have you ever had a reaction to a skincare product, beauty product, or professional treatment?
*
Yes
No
If "yes", please explain what products or treatments, and when this occured.
Do you smoke?
*
Yes
No
Do you use fabric softener in the dryer?
*
Yes
No
Do you regularly swim in a pool?
*
Yes
No
Are you currently under a lot of stress? (Breakup, new job, loss of job, wedding, commute, schedule, etc.)
*
Yes
No
Do you use birth control pills or an IUD?
*
Pill
IUD
No
Other
Allergies
Are you allergic to the following?
*
Sulfur
Asprin
Latex
None
Do you have any other known allergies (to substances or food)?
*
Diet
This is a no judgement zone! Please accurately complete this section.
Do you regularly consume any of the following?
*
Fast Food
Processed Food
Salty Snacks
Milk/Yogurt
Cheese
Whey or Soy Protein
Peanut Butter
Peanuts
Sushi
Kelp or Seaweed
Miso Soup
Soy
Seafood
Please list all vitamins that you currently take.
*
Please include name of vitamin, brand, and dosage.
Beauty Products
You will need to list brand names and item names of all products you use regularly. Please write "n/a" if you do not use a given product.
Cleanser
*
Toner
*
Serums
*
Moisturizer
*
Facial Sunscreen
*
Treatment Masks
*
Makeup Remover
*
Foundation
*
Blush/Bronzer
*
Exfoliants
*
scrubs, acids, exfoliating serums
Acne Medications
*
topical or ingested
Anything else?
*
Treatment History
In the last 90 days, have you had any of the following treatments? If so, when and where?
Chemical Peels
*
Yes
No
If YES, when and where?
DATE OF PROCEDURE, BUSINESS WHERE PROCEDURE WAS COMPLETED.
Microdermabrasion
*
Yes
No
If YES, when and where?
DATE OF PROCEDURE, BUSINESS WHERE PROCEDURE WAS COMPLETED.
Laser Hair Reduction (on face)
*
Yes
No
If YES, when and where?
DATE OF PROCEDURE, BUSINESS WHERE PROCEDURE WAS COMPLETED.
Laser Rejuvenation/Resurfacing
*
Yes
No
If YES, when and where?
DATE OF PROCEDURE, BUSINESS WHERE PROCEDURE WAS COMPLETED.
Skin Cancer Removal
*
Yes
No
If YES, when and where?
DATE OF PROCEDURE, BUSINESS WHERE PROCEDURE WAS COMPLETED.
Facial Waxing
*
Yes
No
If YES, when and where?
DATE OF PROCEDURE, BUSINESS WHERE PROCEDURE WAS COMPLETED.
Electrolysis
*
Yes
No
If YES, when and where?
DATE OF PROCEDURE, BUSINESS WHERE PROCEDURE WAS COMPLETED.
Signature
*
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/skin care therapist of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.
Clear
Date
*
-
Month
-
Day
Year
Date
Client Agreement
Please initial the agreements below and sign at the bottom.
We must adjust your home care routine every two weeks to keep your progress to clear skin moving forward. If we don’t change how you do your home care often enough, your skin will adapt to the regimen and stop responding (in other words, you won’t get clear). I agree to contact my skincare professional so we can adjust your home care regimen at least every two weeks
INITIALS
*
Each time we strengthen your home care, we run the risk of drying and irritating your skin, so you will need to communicate that to us if that happens. I agree to contact my skincare professional if my skin gets uncomfortably dry and irritated.
INITIALS
*
I will not use any other products that have not been approved by my skincare professional while I am on their regimen.
INITIALS
*
I will not change the regimen given to me by my skincare professional without notifying or consulting with them first.
INITIALS
*
I will not run out of product while working with my skincare professional. When you stop using products (or run out) acne will start forming inside the pores and you will see it about a month later.
INITIALS
*
I will not have other skin care treatments while I am being treated by my skincare professional.
INITIALS
*
I will inform my skincare professional of any medications/drugs that I start taking while using their regimen.
INITIALS
*
I will use my sunscreen every morning, regardless of whether or not I will be going outside. The sunscreen will help to keep your skin moisturized. Without it, your skin will get too dry.
INITIALS
*
I will not get sunburned or wind burned while being treated by my skincare professional. (You will not be able to use your active products; and we will not be able to do treatments on you.)
INITIALS
*
I will inform my skincare professional if I elect to do any laser treatments or waxing for hair removal.
INITIALS
*
I will inform my skincare professional if I get pregnant.
INITIALS
*
I understand that photos are taken for medical records, whether I consent to these photos being used for marketing or not. Photos help to track the progress of my treatment and I understand they are critical.
INITIALS
*
MOST IMPORTANTLY: If we are unable to improve the condition of your skin due to factors beyond our control, but within yours, we reserve the right to decline treatments. (That is, if you are not following our instructions pertaining to home care, doing your home care, lifestyle issues, etc.)
INITIALS
*
I,
FULL NAME
*
, hereby agree to all-of the above policies.
Date
*
-
Month
-
Day
Year
Date
Signature
*
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.
Clear
OPTIONAL: Photo Release
If permitted, you grant Live by Skin, LLC permission to use your photographs and treatment notes in their publications, advertising and other forms of media. You understand these items will be reused, published, and republished individually or in connection with other material, in any and all media now or hereafter known, including the internet, printing and for any purpose whatsoever, specifically including, promotion, marketing, advertising and trade, without restriction as to alteration.
Do you consent to photos for marketing purposes?
*
Yes
No
Signature
*
Clear
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: