Acne Intake Form

Acne Intake Form

This is a very in-depth questionnaire. Take a deep breath and please take your time. If you rush through this form, I am almost certain you will rush through your routine, which is not the way to get results. Acne treatment is not something we can rush. Patience and commitment are required as acne is never fully cured, it is only managed. 🖤 I say all of this with love.
What is acne?

Acne is an inherited disorder of the pores where dead skin cells shed much faster than normal. Normal pores shed approximately 1 layer of dead skin cells per day inside the pore. Acne-prone pores shed up to 5 layers of dead skin cells per day, causing buildup. This buildup forms a microcomedone, which is where all acne lesions begin. That microcomedone turns into blackheads or whiteheads under the skin; and if bacteria is present, it feeds on the dead skin cells and oil, creating inflamed pimples or pustules, and possibly cysts. This process can take up to 90 days
Name

First NameLast Name
Birthdate

MonthDayYear
Date
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
What days/times are you available for appointments?
EXAMPLE: I am available after 2pm on Mondays, before 12pm Tuesday-Thursday, and all day on Fridays.
How long have you struggled with acne? Can you pinpoint a trigger?
Have you ever had a facial or treatment for through an esthetician or dermatologist? If yes, please detail your experience. Were you happy with the service?
How would you describe your skin?

oilydrycombinationnormalsensitive
Are you pregnant, nursing or planning to become pregnant?
Do you have ANY health conditions, mental or physical? If yes, please explain.
EXAMPLE: depression, annxiety, stress, eczema, HIV/AIDS, thyroid problems, PCOS, PMDD, blood pressure problems, cold sores, lupus, anemia, etc.
Do you have any metal rods or implants in your body?
Do you have any allergies? If so, please list.
Have you taken ANY medications in the last 90 days?
EXAMPLE: antibiotics, blood pressure medications, SSRIs, etc.
Do you use/take any of the following?

birth controlenergy drinksscented laundry detergentdryer sheetsdietary supplements (ex.- vitamins, Nutrafol, AG1)retinol/differinaccutanenicotinealcoholchlorinated pools/hot tubshand lotion
If you selected any of the above, please specify brand names- if applicable and how long/often you use any of the above.
EXAMPLE: Yaz birth control- 2 years, Celsius Energy Drinks- 3/day for 6 months, Gain Detergent- 5+ years, anccutane- 5 years ago for 6 months, alcohol- socially etc.
Do you regularly (1-3+ times per week) consume any of the following?

eggsdairyshellfishpeanuts/peanut buttercandy/sweetsfast foodspicy food (acne rosacea)
How often do you change your pillowcase?

DailyWeeklyBi-weeklyMonthly+++
Do you wear sunscreen daily?

YesNo
Do you pick at your skin?

YesNo
What is your morning skincare routine? Be as specific as possible about the products you use and the order you apply them.
If it’s easier, you may submit a photo below.
AM skincare routine

please place products in the order you use/apply them.
Cancelof
What is your evening skincare routine? Be as specific as possible about the products you use and the order you apply them.
If it’s easier, you may submit a photo below.
PM skincare routine

please place products in the order you use/apply them.
Cancelof
Are there any fragrances you like or dislike?
During your treatment, do you consent to acne extractions?

YesNo
What is your budget for a full skincare routine?
I can work with all budgets.
Anything else you’d like me to know?
What will Skin Deep do with all this information?

Any answers provided on this form are confidential and will not be used for anything other than providing services at Skin Deep. Please understand that there is absolutely no judgment towards any answers you provide and I only wish to understand your skin better and help you achieve your goals.
By signing, I agree to the following

I will inform my esthetician of any changesI will follow my esthetician’s recommendationsI will not incorporate any new products or supplements without permissionI will allow Before and After photos (these are to monitor progress and will not be shared without permission)I will remind my esthetician to take above mentioned photos if she forgets 🙈🤣I will reach out if I’m feeling uncomfortable or confused with any part of the routine or following any treatmentI will not use Google, TikTok, Facebook, Instagram, or any other form of social media for acne advice.I will trust my esthetician because she knows MY skin
By signing, I also understand that Acne Bootcamp does not take the place of medical advice and I may need a medical professional in certain situations. I may also need to incorporate different products into my routine in order to achieve clear skin. I understand that my home care routine provides 80% of my results, and I agree to complete my routine and follow directions to the best of my ability.
Should be Empty:

Acne Intake Form

What is acne?

What will Skin Deep do with all this information?