New Virtual Client Intake Form

Virtual Program

New Client Intake Form
Today's date
Client's Name*

First Name Last Name
Date of Birth *

Month Day Year
Teens under the age of 14 must start with our Tween Kit for at least 6 weeks. This program is not suited for young teens under 14 years old.
Gender*

MaleFemalePrefer not to answerOther
Contact Number:*
E-mail*
example@example.com
Address:*

Street Address

Street Address Line 2

City State

Postal / Zip Code Country
Teen client

If a client is a minor, please provide the information below.
Parent's Name

First Name Last Name
Parent's Phone Number
Parent's Email
example@example.com
In order for us to create the safest and most effective acne care plan which is customized just for YOU, we must collect certain personal and medical information. Face 5 will never share or disclose any information that you provide to us. You must answer the all of the following questions for us to be able to proceed with your initial consultation and treatment. Do you accept these terms?*
Client Questionnaire
Which of the following prescriptions, over-the-counter drugs or recreational drugs have you used or are currently using?

Accutane/IsotretinoinOral AntibioticsTopical AntibioticsRetin A CreamRein A GelAldactone/SpironolactoneBenzoyl Peroxide (BPO)Benzamycin (BPO+Erythromycin)Aczone (Dapsone)BenzaClin/Duac?Acanya/Onexton (BPO+Clindamycin)Tazorac (Avage Gel)Tazorac (Avage Cream)ZianaDifferinEpiduo (Differin+BPO)SulfurZiana (Tretinon+Clindamycin)Finacea/Azelex/Metrogel/MirvasoCortisone InjectionsThyroid MedicationTestosteroneProgesteroneDisufuramSteroidsMarijuanaRecreational DrugsAntidepressantsOther
If other, please list here.
If you've selected any of the above drugs/medications, please verify which medication you are on now, or when you have used and how long. * Accutane/Isotretinoin must be stopped at least 4 months before starting our Acne Solution Program.
Please identify any skin treatments you have received?

Chemical PeelMicrodermabrasionSkin Cancer RemovalPlastic SurgeryLaser Hair RemovalElectrosisLED TherapyMicroneedlingLaser TreatmentPhoto FacialBotox/JuvedermOther
If other, please list here
Please describe the results from any treatments you have received?
Medical History
Please identify any conditions you may have had in the past two years.

DiabetesThyroid ProblemsEczemaPsoriasisPregnancyNursingCancerHepatitisHIV+ or AIDSStaph Infection or MRSAHormone ProblemsHerpes Simplex/Cold SoresHigh Blood PressureAnemiaHemophiliaThrombosis/Blood Clot/StrokeMetal Pins or brackets in bodyPacemakerHysterectomy/ovaries removalPCOSLupusADD/ADHDOther
If other, please list here.
Are you taking any medications for your medical problems? If yes, please list all the medication you are taking.
Are you under a Dermatologist's care?
Allergies
Please check if you are allergic to the following medications:*

SulfurAspirinLatexBenzoyl PeroxideNone of aboveOther
If other, please list here.
Have you ever had any reactions to anything you have ever put on your skin? If yes, please explain.
Your acne and your skin
At what age did your acne start?
Have you ever been diagnosed with Rosacea?
Where are you experiencing acne problems? (Please check all that apply)

ForeheadHair lineCheeksChinNoseJawlineFront of neckBack of neckBackShouldersOther
Which area of acne, would you like us to treat? (Face, Chest, and/or Back?)*
How would you describe your skin?

OilyNormalDryOily and Dry Combination
What are your skin concerns (Please check all that apply):

BlackheadsWhiteheadsPimples/PustulesCystsDark spots / Acne Scars / HyperpigmentationsBroken CapillariesShaving IrritationLazer BumpsSensitive Skin
With sun exposure, your skin...
Do you form thick or raised scarring (Keloid) from cuts or burns?
Do you pick at your skin?
Do you get waxing services on your body or face regularly?
What is your ethnic background? Please provide as much detail as possible.
Lifestyle Considerations
Do you use fabric softener or dryer sheets ?*
Do you smoke?*
What kind of work do you do? Or are you a student (High School, College, etc)?*
Do you play any sports? Or do you work out regularly? If yes, please describe what and how often.
Please list all the skincare products you are currently using. (brand and name)*
Please list all your makeup products you are currently using. (brand and name) If you do not use makeup, please write none.*
Please list all of the haircare products (include shampoo and conditioner) that you are currently using. (brand and name). *
What toothpaste do you use? (brand and name)?*
Do you work around chemicals, tars, oils or inks?
Do you regularly consume any of the following:

KelpSeaweedSushiSaltFast FoodMilkCheeseProtein Shakes/Protein Bars
Do you follow any special diet?
Do you take any supplements, vitamins, protein powder, homeopathic medicines?
Please explain your purpose for using any of these products.
Please rate your stress level (1 = no stress, 5 = high level of stress)

1

2

3

4

5

1 is no stress, 5 is high level of stress
Have you used or are you using Clarisonic or any type of face brushes?
If you answered yes to the use of Clarisonic or face brush, please tell us how long and how often you have used this. *Please stop using any type of face brush if you are going to receive our treatment.
Could you tell us about your typical day? (e.g. I get up at 6 am and leave for school at 7 am. I have a gym class at 9 am. I have baseball practice every day after school and games 2/week and some on weekends. I take shower at night.)
Women Only
Are you currently using birth control pills?
If yes, name of pill :
Are you currently taking Depo Provera shots?
Are you currently using any other birth control devices, such as IUD? Please list.
Are you pregnant or nursing?
Are you taking any hormonal medications?
Compliance Assessment: 1=not willing, 5=very willing
Follow a multi-step home care regimen twice per day:*

1

2

3

4

5

1 is Not willing, 5 is Very villing
Significantly modify your diet : *

1

2

3

4

5

1 is Not willing, 5 is Very willing
Take nutritional supplements everyday :*

1

2

3

4

5

1 is Not willing, 5 is Very willing
Modify your lifestyle (e.g. stop picking, stop tanning, stop drug use/smoking, etc)*

1

2

3

4

5

1 is Not willing, 5 is Very willing
What kind of result are you looking for ?*
How did you hear about us? Who should we thank? (Please mention the name so we can thank this special person.) If you found us through an online search, please let us know where or how you found us. Facebook/Instagram/Google/Yelp *
Is there anything else you would like to tell us?
Please upload 3 pictures.

For face acne: right, center, and left side of your face. Be sure to include the whole face. For back acne: Be sure to include the upper shoulder.
Can Face 5 email you newsletter and updates? We send out only educational information about acne and what is happening at Face 5.*

YES, I would like to keep in touch with all of Face 5 updates.YES, but I only the important information, not promotion emails.NO, I do not wish to receive any email from Face 5.
Important note for new clients
If you are using any topical medication (include OTC Retin A) , we will need you to stop using for at least two weeks before you start with our program. If you are on Accutane/Isotretinnoin , we will need you to stop 4 months before starting our Acne Solution Program. If you are pregnant or nursing, we require your doctor's OK before you start our program.*

I understood and I am all goodI need to reschedule
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.*

I understood
Please sign to agree that the information you have provided here is true and you have read and understood the questions above.
Signature*

Clear
If the client is under the age of 18, signature by the responsible party here.
Relationship to the client
Signature

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Virtual Program

Teen client

Please upload 3 pictures.