New Acne Client Questionaire
Virtual Consultation
Date
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Birthdate
Age
How did you hear about Sarah Pierce Aesthetics?
Back
Next
What is your hereditary background? (Select all that apply)
Nordic
Scandinavian
Irish
Engish
German
European
Eastern European
Mediterranean
Hispanic
Native American
South American
Middle Eastern
Islander
African American
Asian
Indian
Other
Natural Eye Color
Natural Hair Color
Do you consider your skin (please choose the best option)
Sensitive
Resilient
Unsure
Other
What is your skin goal?
Describe your skin (please choose all that apply):
Normal
Dry
Combination
Thick
Thin
Oily
Acne
Blackheads
Texture
Milia
Cysts
Breakouts
Acne-Scarred
Large Pores
Small Pores
Rosacea
Eczema
Psoriasis
Freckled
Sun-damaged
Melasma
Hyperpigmentation
Hypopigmentation
Uneven/Blotchy
Mature
Wrinkled
Patchy Dryness
Dehydrated/Lacking Moisture
Other
Back
Next
Medications
Currently Using
Previously Used
Antibiotics
Accutane
Benzoyl Peroxide
Retin A (Vitamin A/ Retinol)
Tazorac
Differin
Epiduo
Azelex
Avita
Cleocin-T
E-mycin -T
Copaxone
Corticosteroids
Quinine
Steriods
Marijana
Cocaine/Speed
Please list any other current medications:
Back
Next
Medical History
Cold Sores
Eczema
Psoriasis
Hepatitis
PCOS
Cancer
Staph/ MSRA
HIV/AIDS
Thyroid Problems
Hormone Problems
Hysterectomy
IVF Treatments
Fertility Treatments
Ovaries Removed
Pacemaker
Hemophilia
Lupus
Anemia
High Blood Pressure
Skin Tags
Diabetes
Metal Pins in the body
Other
Back
Next
Please list your current skincare routine:
Have you had any bad reaction to anything you put on your face? If so, please list in detail
Are you allergic to the following?
Sulfur
Latex
Aspirin
Other
Please list any known allergies:
Do you smoke?
Please Select
No
Yes
Do you regularly swim in a chlorinated pool?
Please Select
No
Yes
Do you use fabric softeners or dryer sheets?
Please Select
No
Yes
Do you work around chemicals, tars or grease?
Please Select
No
Yes
Occupation:
Do you work nights?
Please Select
No
Yes
Are you currently under stress? (new job, job loss, wedding, romantic breakup, school, death of a loved one, graduation, difficult home life, long commute, heavily scheduled, new parent, recently moved, medical condition)
Are you a vegetarian or a vegan?
Please Select
vegetarian
vegan
none of the above
Do you like to spend time outdoors?
Please Select
Yes, lots
Yes, a little
No
Do you develop cold sores/blisters?
Please Select
Yes
No
Have you used Accutane (isotretinoin) in the past 6 months?
Please Select
Yes
No
Women Only: Are you pregnant, trying to become pregnant, or nursing?
Please Select
Pregnant
Trying to become Pregnant
Nursing
Not Pregnant, trying or nursing
Women Only: Are you using a hormonal birth control? If so, please list:
Men Only: Do you have shaving/ irritation on your face?
Back
Next
Please indicate how often you eat the following:
Daily
Weekly
A few times a month
Monthly
Never
Fast Food
Processed Food
Salty Snacks
Milk
Yogurt
Cheese
Other Dairy
Whey or Soy
Peanut Butter
Peanuts
Sushi
Kelp/ Seaweed
MIso Soup
Soy
Seafood
Sugary Foods
Alcohol
Please list any vitamins you currently take:
Have you had any of the following treatments in the past 90 days?
Peel
Microdermabrasion
Laser Hair Removal on Face
Laser on Face
Skin Cancer Removal
Facial Waxing/ Removal
Electrolysis
Fillers, Botox, injections on the face
Other
Back
Next
Acne Treatment and Consent: An acne treatment may consist of surface cleansing, mild chemical peels or steam and exfoliation, application of antibacterial serums, corrective serums and extractions. Treatments take approximately 30 to 75 minutes to complete and are designed to balance, hydrate, clear acne impactions and prepare the skin for home care. Implements and equipment used in this facility are disposable or properly sterilized according to the State Board of Cosmetology regulations.
Please read and initial the following carefully:
I have not had any chemical peel of any kind 14 days prior to this appointment. I understand that I cannot have any other treatments performed to my face without consulting Sarah Pierce Aesthetics.
Initial
I have not had any facial waxing within 7 days of this treatment. I will not get waxing for 7 days following this treatment.
Initial
I have informed Sarah Pierce Aesthetics of any topical or oral medications I am using, including Retinoids (Retin-A, Renova, Avita, Differin, Tazorac), Accutane, or antibiotics.
Initial
I agreed I have not been exposed to excessive sun or wind and my skin is not irritated in anyway. I understand my skin cannot be compromised to receive treatments.
Initial
I recognize that the products Sarah Pierce Aesthetics recommends are clinical strength active formulas that are designed to treat problematic skin. Tingling sensations are normal with product application but should not be painful. If I experience pain or discomfort, I will contact Sarah Pierce Aesthetics.
Initial
I agree not to pick at my acne, as it may inhibit my progress and treatments.
Initial
I agree to wear SPF everyday.
Initial
I understand that I may experience much visible peeling, flaking, discoloration, or irritation during this program. I agree to follow my homecare to help with healing of my skin.
Initial
I understand that controlling acne is best achieved through check-ins every two weeks, using homecare as directed, and following all diet and lifestyle recommendations. I understand that without following the suggestions by Sarah Pierce Aesthetics, I may not get my desired results.
Initial
I consent to photographs taken of my for to be used for monitoring treatment progress.
Initial
I consent to photographs taken of me and my skin be used on social media for educational purposes.
Initial
I have informed Sarah Pierce Aesthetics of all health problems that I am aware of.
Initial
I agree to the above and consent to the treatments performed on me. I agree that I will inform Sarah Pierce Aesthetics of any changes to my skin. I agree to follow homecare and post-treatment instructions.
(Yes or No)
Print Name
First Name
Last Name
Name of Parent/ Guardian (if under 18)
First Name
Last Name
Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: