The Skin Twins Acne Consultation Form

Name*

First NameLast Name

Age*

Gender

Date of Birth*

MonthDayYear

Email*

example@example.com

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Ethnicity*

Tell me a little bit about yourself and how long you've been dealing with your acne. *

Please select your primary skin concerns:

Rows	Please select:
Acne
Aging
Texture
Pigmentation
Pore Size
Scarring
Sunburn
Elasticity
Other

Please list any additional skin concerns and your long term goals:*

Please list any other medications or drugs listed that you have used in the past 2 years and include when they were used, and for how long you used them:

MEDICAL HISTORY (PLEASE CHECK ALL THAT APPLY):

Rows	Yes	No
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

Please indicate if you have used any of the medications or drugs listed below in the last 2 years, when they were used, and for how long you used them.

Rows	When	How Long	Last taken/Used
Antibiotics (Oral)
Antibiotics (Topical)
Accutane
Benzoy Peroxide
Estrogen
Testosterone
Progesterone
Retin-A
Retinol
Tretinoin
Tazorac
Differin
Clindamyein
Quinine
Lithium
Thyroid
Azelex
Celocin-T
E-Myein-T
Compaxone
Corticosteriods
Androstenedione
Danzol
Isoniazid
Steroids
Marijuana
Cocaine/Speed
Other
None

What are your breakouts like? How frequent are they?*

YesNo

If yes, what product(s) were you reactive to?

YesNoSometimes

AverageHighLow

What laundry detergent are you using? *

Dryer sheetsSoftenerBothNone

YesNoSometimes

If so, list any supplements you’re taking for working out. Ex: protien powder, preworkout, creatine, etc.

YesNo

What toothpaste are you using? Include brand and name*

YesNo

If yes, how long ago and how frequent?

If you’ve had a facial before, what did you like about your facial(s)?*

YesNoKinda?

If yes, what products are you currently using? (Please go into detail, include product name and brand, how long you've been using them, and your overall experience for each product.)

RegularlySometimesNever

YesNoI don't know

YesNo

If so, please list them here.

YesNo

Do you use birth control pills, shot, or IUD? If so, Which kind?

Are you taking any supplements? Greens, prenatal, vitamins, list any and ALL.*

PregnantNursingTrying to concieveNone

What is your monthly budget for skincare products?*

What is your monthly budget for treatments? *

List all hair care products. Shampoo, conditioner, masks, leave in, etc. (please include brands and names of products) *

YesNo

How did you hear about me?*

Ex, Instagram, Snapchat, Friend (specific name) or family member, etc.

Submit photos of your face (front, both sides, and any other areas affected). *

YesNoYes but block out my eyes

Feel free to share any questions or concerns you have.

Clearing and managing acne is a process that can take time, patience, commitment, and sometimes major lifestyle changes. By selecting "I Understand", you acknowledge the depth of the process and agree to work with me as a team with no timeline expectations.

I UnderstandI would like to chat about this

By selecting "I Understand", you acknowledge that I am a Licensed Esthetician and skincare professional with your best interests in mind at all times. You also understand that steering from any guidance you receive may lead to unwanted, delayed, or an altogether lack of results.

I UnderstandI would like to chat about this

Signature

If under the age of 18, Parent or Guardian please sign here.

By signing here, you acknowledge and agree to the following above.

Cancellation/No-Show/Reschedule Policies:

The Skin Twins sends out multiple appointment reminders: first when your appointment is made, 48 hours before your appointment, 24 hours before your appointment, and 1 hour before your appointment via email and text. You are given multiple chances to cancel/reschedule ahead of your appointment to avoid the different fees.

The Skin Twins asks that you please reschedule or cancel at least 48 hours in advance or you will be charged a 50% cancellation/rescheduling fee. Any no-shows or cancellations/reschedules with 12 hours or less notice will be charged 100% of the service fee.

Failure to pay cancellation or rescheduling fees will result in blockage from booking future appointments until paid. After 2 no-shows or same day cancellations, you will not be able to book further appointments with The Skin Twins.

Reschedules with less than 24 hours notice will be required to adhere to the above mentioned policies for cancellations.

Grace Period Policy:

The Skin Twins gives a 10-minute grace period to arrive to your appointment. Clients that are late to their appointments may run the risk of their treatments/appointments being shortened but still charged the full service fee OR may be required to pay 100% of the service fee and reschedule.

Under-age Client Policy:

All clients under the age of 18 are required to have a parent or legal guardian present at all of their appointments.

Guests Policy:

For liability reasons, no other guests may be present at your appointment unless you are an under-age client attending with your parent or legal guardian.

Compliance to Guidance:

Due to the nature of the business, The Skin Twins frequently gives clients instructions for treatment pre- and post-care, home care products, lifestyle factors, etc., that affects client skin progress and health. By signing below, you understanding that you must follow any and all instructions given to you by your provider and understand that failure to do so may result in lack of results or compromised skin health due to failure to adhere to policier and guidance on your part and do not hold The Skin Twins liable.

Credit Card On-File Policy:

An active credit card is required to be on file for each client in case of failure to adhere to any of the above mentioned cancellation, no-show, or rescheduling policies. You will on be charged with the card on file in case of failure of adherence to these policies or unless the card on file is your chosen payment preference for treatments, products, etc. If your card on file is declined, you will be asked to pay via a different method or may risk being blocked from future treatments and purchases from The Skin Twins and you will also be asked to update the card on file. You will be asked to provide your card info below and authorize The Skin Twins to add your payment card to your file.

We appreciate your understanding and compliance!

I have read and acknowledge The Skin Twins policies and standards:

The Skin Twins Acne Consultation Form

CLIENT INFORMATION

LIFESTYLE CONSIDERATIONS

The Skin Twins Policies