Ethnicity
If you selected other, please specify .
Your primary care physician: First Name Last Name Phone Number Please list dermatologist if applicable First Name Last Name Phone Number
Have you ever had any reaction to any products or anything you have put on your face Yes No If yes, what products? Please check any of these you are allergic to: Sulfur Asprin Latex Do you smoke/vape? Yes No Do you use fabric sofener of fabric softener sheets in the dryer? Yes No Do you swim in a chlorinated pool? Yes No Do you work around chemicals, tars, oils, grease or inks? Yes No Are you currently under a lot of stress? Yes No Do you use birth control pills, shots, or IUD?Yes No If yes, which do you use & what brand? Are you pregnant or nursing? Yes No Do you have shaving irritation on your face? Yes No
Products Currently Using - Please Provide Product NamesCleanser Toner Type a label Serums Type a label Moisturizers Type a label Sunscreen Type a label Mask Type a label Foundation Type a label Blush Type a label Exfoliant (Acids, serums, scrubs) Type a label Acne Medications Type a label Anything else? Type a label
If yes to any of the treatmens above, please specify when & where Type a label How did you hear about us? Type a label
Initals* We must adjust your home care routine every 2 weeks to keep your progress to clear skin movingforward. If we don’t change how you use your home care often enough, your skin will adapt to the routine and stop responding (in other words, you won’t get clear). I agree to contact my Acne Expert to adjust my home care routine at least every 2 weeks.Initials * Each time we strengthen your home care, we run the risk of drying and irritating your skin, so you will need to communicate that to us if that happens. I agree to contact my Acne Expert if my skingets uncomfortably dry and irritated.Initials * I will not use any other products that have not been approved by my Acne Expert while I am in their acne program.Initials * I will not change the routine given to me by my Acne Expert without notifying or consulting with them first.Initials * I will not run out of product while working with my Acne Expert. Skipping products (or running out will cause acne to start forming inside the pores and it will come to the surface in 30 - 90 days.)Initials * I will not have other skin care treatments while I am being treated by my Acne Expert. Initials * I will inform my Acne Expert of any medications/drugs that I start or stop taking while I am in their acne program.Initials * I will use my sunscreen every morning, whether I go outside or not. I can be exposed to UV rays through windows.Initials * I will not get sunburned or wind burned while being treated by my Acne Expert. (You will not be able to use your active products; and we will not be able to do treatments on you.)Initials * I will inform my Acne Expert if I elect to do any laser treatments or waxing for hair removal.Initials * (For women) - I will inform my Acne Expert if I become pregnant.Initials * MOST IMPORTANTLY: If we are unable to improve the condition of your skin due to factors beyond our control, but within yours, we reserve the right to decline treatments. (That is, if you are not following our instructions pertaining to home care, doing your home care, lifestyle issues, etc.)I, Signature* hereby agree to all of the above policies Date*