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    Nancy Russ Skin Care Solutions

    602 W Indian River Blvd, Suite 3

    Edgewater , FL  32132

    386-689-9161

    nancy@nancyruss.com

  • All About You

  • Format: (000) 000-0000.
  • Home or Cell Phone*
  • Date Of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • How would you like to work with me?*
  • Areas of Concern?*
  • How much time are you realistically willing to spend on your home-care routine?*

  • Please upload 3 clear photos of your skin without makeup or filters, taken in good natural lighting:

  • Front view*
  • Left side*
  • Right side*
  • I am concerned with the following:*

  • Please list all prescription medications, over-the-counter medications, hormones and supplements your currently take

  • Medical History

    Do you currently have, or have you been previously diagnosed with any of the following? Check all that apply.
  • Conditions*
  • Are you under a dermatologist's or other physician's care?*
  • Are you currently pregnant, breastfeeding, or trying to become pregnant?*

  • Lifestyle Considerations

  • Do any of the following apply to you?Check all that apply.*
  • How often do you change your pillowcase?*
  • Have you ever had a negative reaction to a product used on your skin?*
  • Do you have any known allergies?*
  • Do you work night shifts or have an irregular work/sleep schedule?*

  • Diet & Supplements

    Do your regularly consume or use any of the following? Check all that apply.
  • Check off foods you consume:*

  • Show Me What You're Using

    Your current products aren't necessarily “bad” products. However, they may not be the right combination for your skin, may contain ingredients that aren't ideal for acne-prone skin, or may simply not be helping you reach your goals. Part of your assessment includes reviewing your current routine and determining what should stay, what may need to change, and what may be missing. Please upload clear photos of ALL products that regularly touch your face, hair or acne-prone areas. Include skincare, makeup, sunscreen, hair products and any prescription or over-the-counter acne products. Please make sure the product name is visible.

  • Acne Program Commitment

    Successful acne management requires consistency both in and outside the treatment room. Professional treatments are only one part of the process. Your daily home-care routine and willingness to follow recommendations are essential.

    By participating in my acne program, you agree to follow your recommended home-care routine, communicate any reactions or concerns, attend recommended follow-ups, and discuss changes with me before adding, stopping, or substituting products.

    Because acne can be influenced by many factors, specific results or timelines cannot be guaranteed.

  • Product & Home-Care Policy

    Your personalized home-care routine is an important part of your acne program. Products are selected based on your skin, acne type, current routine, and individual needs.

    To accurately monitor your progress and make appropriate adjustments, I ask that recommended products be purchased through Nancy Russ Skin Care Solutions or an approved source provided by me. Please do not substitute products or add new skin-care products without discussing them with me first.

    If you choose to use products outside of your recommended routine, I may be unable to accurately evaluate your progress or make appropriate adjustments to your acne program.

  • Medical Disclaimer

    This Acne Assessment is intended for educational purposes only and is designed to help identify possible acne triggers and provide general skincare guidance. It is not a medical diagnosis and should not be used as a substitute for evaluation or treatment by a licensed healthcare provider.

    The recommendations provided are based on the information you submit and are not guaranteed to address your specific skin concerns. Individual skin conditions and treatment responses vary.

    If you have severe, persistent, painful, or rapidly worsening acne, signs of infection, or any other concerning skin condition, please consult a qualified dermatologist or healthcare professional for a comprehensive evaluation and appropriate medical care.

    By completing this quiz, you acknowledge that the information provided is educational in nature and does not establish a patient-provider relationship.

    Any questions please text us at 386-689-9161 and we will be happy to speak to you!

  • Date
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    2 digit month, 2 digit day, 4 digit year
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