Free Consultation Form
Please fill out the information below to the best of your ability. Our lead esthetician will then review it and recommend a program for your condition!
Are you inquiring for yourself or behalf of your child?
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Myself
My Child
First Name
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Last Name
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Client Name
First Name
Last Name
Parent/Guardian Name
First Name
Last Name
Email (Parent's email if a client is a minor)
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example@example.com
Phone Number (Parent's phone number if a client is a minor)
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Please enter a valid phone number.
Format: (000) 000-0000.
Client Information
Please ensure all the information below is reference to the potential client receiving treatment. Please Note, in order for us to create the safest and most effective acne care plan which is customized just for YOU, we must collect certain personal and medical information. Face Five Acne Clinic will never share or disclose any information that you provide to us.
Age
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Gender
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Male
Female
Location (City)
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Skin Considerations
At what age did you acne start?
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How would you describe your skin?
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Oily
Dry
Oily and Dry
Sensitive
Other
What are your main skin concerns? Please share as much as you like below.
If applicable, please describe the results you've seen from previous skin treatments
If you are comfortable doing so, please upload a selfie of you or your child's face or body. Take a picture of each side of your face like the example below. If you're on mobile, feel free to use the image capture below instead!
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Browse Files
Drag and drop files here
Choose a file
Acne is a very personal problem, and we applaud you for willing to share with us so that we can potentially assist you. Any images submitted will only be utilized for the purpose of initial assessment and will be deleted after we provide our virtual consult.
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of
Photo 1 - Left Side
Photo 2 - Right Side
Medical History
Please identify any conditions you may have had in the past two years.
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Diabetes
Thyroid Problems
Eczema
Psoriasis
Pregnancy
Nursing
Cancer
Hepatitis
HIV+ or AIDS
Staph Infection or MRSA
Hormone Problems
Herpes Simplex/Cold Sores
High Blood Pressure
Anemia
Hemophilia
Thrombosis/Blood Clot/Stroke
Metal Pins or brackets in body
Pacemaker
Hysterectomy/ovaries removal
PCOS
Lupus
ADD/ADHD
None of the above
Other
If you chose other, please list the other condition here.
Are you taking any medications? If yes, please list here.
Have you seen, or are you currently under the care of a dermatologist?
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Yes
No
Which of the following prescriptions have you used to try and treat your acne?
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Accutane/Isotretinoin
Oral Antibiotics
Topical Antibiotics
Retin A Cream / Tretinoin
Retin A Gel
Aldactone/Spironolactone
Benzoyl Peroxide (BPO)
Benzamycin (BPO+Erythromycin)
Aczone (Dapsone)
BenzaClin/Duac/Acanya/Onexton (BPO+Clindamycin)
Tazorac (Avage Gel)
Tazorac (Avage Cream)
Differin
Epiduo (Differin+BPO)
Sulfur
Ziana (Tretinon+Clindamycin)
Finacea/Azelex/Metrogel/Mirvaso
Cortisone Injections
Thyroid Medication
Testosterone
Progesterone
Disufuram
Non of above
Other
If you chose other, please list the other prescriptions here.
Are you taking any of the following over-the-counter or recreational drugs?
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Steroids
Antidepressants
Marijuana
Recreational Drugs
Don't take anything mentioned above
Other
If you chose other, please list the other over-the-counter or recreational drugs here.
Are you allergic to any of the following medications?
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Sulfur
Aspirin
Latex
Benzoyl Peroxide
None
Other
Have you ever had any reactions to anything you have ever put on your skin? If yes, please explain.
Have you ever been diagnosed with Rosacea?
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Yes
No
I don't know
Please identify any skin treatments you have received?
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Chemical Peel
Microdermabrasion
Skin Cancer Removal
Plastic Surgery
Laser Hair Removal
Electrosis
LED Therapy
Microneedling
Laser Treatment
Photo Facial
Botox/Juvederm
Other
If you chose other, please list the other skin treatments here.
Lifestyle Consideration
What kind of work do you do? Or are you a student (High School, College, etc)?
Do you play any sports? Or do you work out regularly? If yes, please describe what and how often.
Do you smoke?
Yes
No
Women Only
Are you currently using any type of birth control? (Include IUD, etc.) Please detail below.
Are you pregnant or nursing?
Yes
No
Are you taking any hormonal medications?
Feel free to share any additional questions you have for us below!
By the way, how did you hear about us?
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Please Select
Google
Instagram
Facebook
Referred
Other
We will follow up in relation to this inquiry, but would you also like to subscribe for future announcements and promotions?
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