Acne Intake Form

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.
1. 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 *
2. 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 *
3. I will not use any other products that have not been approved by my skincare professional while I am on their regimen. INITIALS *
4. I will not change the regimen given to me by my skincare professional without notifying or consulting with them first. INITIALS *
5. 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 *
6. I will not have other skin care treatments while I am being treated by my skincare professional. INITIALS *
7. I will inform my skincare professional of any medications/drugs that I start taking while using their regimen. INITIALS *
8. 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 *
9. 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 *
10. I will inform my skincare professional if I elect to do any laser treatments or waxing for hair removal. INITIALS *
11. I will inform my skincare professional if I get pregnant. INITIALS *
12. 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 *
13. 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
Should be Empty:

Acne Intake Form

Health History

Lifestyle Considerations

Allergies

Diet

Beauty Products

Treatment History

Client Agreement

OPTIONAL: Photo Release