ACNE PROGRAM CONSULTATION FORM

ACNE PROGRAM CONSULTATION FORM

Personal & Confidential, please answer all questions honestly!
Please take your time filling out these questions below. Please note that every question has to be answered. If it does not apply to you, please write either "n/a or none". Please make sure to answer the questions honestly! This is important so that I can ensure the best home care regimen and treatment plan for your skin.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Date of birth*

MonthDayYear
Date
Are you under the care of a Dermatologist or Specialty Doctor?*

YesNo
Please list any Medications you are currently on, including vitamins or supplements. *
Medical History
Please check all that apply*

Herpes Simplex (cold sore)EczemaPsoriasisHepatitisCancerStaph Infection/MRSAHIV/AIDSHysterectomyOvary(ies) RemovedPacemakerHemophiliaLupusAnemiaHigh blood pressureDiabetesMetal pins in bodyHormone Replacement TherapyHypothyroidismHyperthyroidismHormone ImbalancePCOSNone of the above
Are you allergic to*

SulfurAspirinLatexNone of the above
Do you have any other known allergies (to ingredients, substances or food?)*
Do you smoke cigarettes or marijuana? (This is a no judgement zone, these can affect skin which is why it’s applicable) Check all that apply*

CigarettesMarijuanaI do not smoke
Please Answer if applicable

this below section applies to any person who may carry or nurse a baby, or any person who may shave their face.
If you use contraceptive birth control (aside from condoms), what has form do you use?

PillShotIUDImplantI do not use birth control
If you answered yes to any of the above, what brand of birth control do you use?
Are you currently pregnant or Nursing?

YesNo
Are you currently trying to conceive?

YesNo
If you shave your face, Do you have problems with irritation?
If yea to the above, What type of razor do you use?
Lifestyle Considerations
Have you ever had a reaction to a skincare product?*

YesNo
If you answered yes, please specify the product(s) and what happened
Have you ever had a reaction to a professional treatment?*

YesNo
If you answered yes, please specify the treatment performed and what happened
Do you use Fabric Softener or Fabric Softener sheets in the dryer?*

YesNo
Do you swim in a chlorinated pool?*

YesNo
Do you work around:*

ChemicalsTarsOilsGreaseInkNone of the above
What is your occupation?*
Do you work the night shift?*

YesNo
How would you rate the stress level of your job?*

LowMediumHigh
Are you currently under a lot of stress AND/OR has a traumatic event happened to you within the last 3 months?*

YesNo
Please select any of these common stress factors*

Job LossNew JobWeddingRomantic BreakupDeath of a family member/friendGraduationDifficult home lifeLong commutesOverworkedOtherNone of these apply
If you chose other, please briefly explained what happened at a level to which you are comfortable talking about it.
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*
Exfoliants*
Serums *
Moisturizers*
Sunscreens*
Masks*
Facial Oils*
Foundation *
Concealer*
Blush*
Bronzer/Contour/Highlight*
Powder*
Setting Spray*
Any other products you use daily?*
Treatment History

In the last 90 days, have you had any of the following treatments? If so, please say yes and the date. If it doesn’t apply, please put N/A
Chemical Peel*
Microdermabrasion *
Laser Hair Removal*
Laser Resurfacing *
Skin Biopsy*
Electrolysis*
IPL*
Diet

This is a no judgement zone! Please accurately complete this section. I recommend writing in your notes/journal the types of food/supplements you eat before your appointment. You can also brainstorm your favorite types of food/supplements you eat or drink on a daily basis. This is extremely important! Any information helps!!
Do you consume any of the following on a regular basis?*

Fast FoodProcessed FoodSalty SnacksMilk or Yogurt (cows milk)CheeseWhey or Soy proteinPeanut ButterPeanutsSushiKelp/seaweed/misoSoy SauceSeafoodNone of the above
Signature

Clear
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.
Before your initial consultation please read the following important steps to follow:

No excessive sun exposure that can lead to sunburns, no tanning beds, etc.No chemical facial treatments within 14 days of your treatment or consultation No facial waxing within 7 days of your consultation or treatmentsDiscontinue any oral or topical prescriptions within 3 days of your consultation or treatmentsDiscontinue any AHA/BHA active ingredients 3 days before your intital consultation these include: Retinol, Salicylic acid, Glycolic acid, Lactic acid, Mandelic acid, Benzoyl Peroxide
I have read and acknowledge the important steps to be taken before my initial consultation **

Yes
Cancellation Policy and Late Policies

I acknowledge that I must adhere to Revival Beauty’s policies. I understand that cancellations must be done with at least 24 hours notice. Failure to do so will result in 100% charge of the total service cost. I acknowledge that any NO CALL, NO SHOW, will also result in 100% charge of the total service cost. We realize emergencies do happen and will be considered.If you are more than 10 minutes late we cannot guarantee that we will be able to fit your appointment into the schedule and you may not be seen. If we cannot fit you in, there will be a 50% fee charged of the service booked for the missed appoitment. By signing below, I have agreed to all these policies.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

ACNE PROGRAM CONSULTATION FORM

Medical History

Please Answer if applicable

Lifestyle Considerations

Beauty Products

Treatment History

Diet

Before your initial consultation please read the following important steps to follow:

Cancellation Policy and Late Policies