Live by Skin Acne Consultation Questionnaire + Deposit

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Name* This field is required.
First Name
Last Name
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Email* This field is required.
example@example.com
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Phone Number* This field is required.
Area Code
Phone Number
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Occupation* This field is required.JOB/STUDENT/ETC.
JOB
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Date of Birth* This field is required.
Date
Year
Month
Day
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How did you hear about Live by Skin?* This field is required.
JOB
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Are you specifically looking to join our acne bootcamp?* This field is required.
Yes
No
Unsure
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Are you looking to schedule a virtual or in-person consultation?* This field is required.We offer both!
Virtually
In Person
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Are you just looking for a customized regimen, or also looking for an in-person treatment plan?* This field is required.We are unable to treat acne unless you commit to a complete custom homecare regimen from Live by Skin.
Homecare Regimen Only
Both Homecare Regimen & In-Clinic Treatments
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Please list all diagnosed allergies:* This field is required.To ingredients, products, foods. Please write n/a if you do not have any.
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Please list all irritants.* This field is required.Have you ever had a bad reaction to a product, treatment, or material but it isn't a diagnosed allergy? List it here. Please write n/a if you do not have any.
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Have you ever, or do you currently take Accutane?* This field is required.Or Isotretinoin, Absorica, Amnesteem, Claravis, Myorisan, Sotret, Zenatane, or any other generic version?
YESNO
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Have you ever, or do you currently use prescription Tretinoin?* This field is required.Atralin, Avita, Refissa, Renova, Retin-A, Retin-A Micro, Tretin-X, or any other generic version?
YESNO
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Have you ever used anything with benzoyl peroxide before?* This field is required.In any form - wash, ointment, cream, spot treatment.
YESNO
15
Please list all other oral and topical medications.* This field is required.Please list even if they are not relevant to skin. You can write n/a if you don't take any!
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Please check all current skin concerns of yours:Anything that is a concern of yours, right now at this moment.
Red, inflamed acne (with or without a white head, and whether it feels "under the skin" or not)
Blackheads
Congestion (flesh colored tiny bumps, congestion is not inflamed or red)
Rosacea
Hyperpigmentation/Acne Scars
Dryness/Dehydration
Sensitive Skin
Excess Oil
Texture/Physical Scarring
Preventative-Aging
Fine Lines
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What is your #1 skincare goal?* This field is required.
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What is your #2 skincare goal?* This field is required.
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Do you have any other goals for your skin?Optional question! If so, please list in order of importance! This is helpful when creating your plan.
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What is holding you back from reaching those goals?* This field is required.This could be things like: difficulty finding time to care for your skin, not knowing what products to use, allergies, products being too expensive for your budget, zero luck with products working for you, etc.
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Large
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Small
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Ok
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MORNING ROUTINE* This field is required.List in order of use in this format: "Brand Name - Product Name" (I.E. 1. Neutrogena - Ultra Gentle Cleanser, 2. Brand Name - Calming Toner 3. Brand name Serum #1, 4. Brand Name - Serum #2).
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Ok
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EVENING ROUTINE:* This field is required.List in order of use in this format: "Brand Name - Product Name" (I.E. 1. Neutrogena - Ultra Gentle Cleanser, 2. Brand Name - Calming Toner 3. Brand name Serum #1, 4. Brand Name - Serum #2).
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Large
Normal
Small
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Ok
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MISCELLANEOUS PRODUCTS:* This field is required.Please list ALL that you own, even if you don't use them but still have them laying around! We will help you declutter and narrow things down. You will feel less cluttered and clear minded!
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Large
Normal
Small
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Ok
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Are you currently receiving professional skincare treatments at your dermatology office or at an esthetic establishment?* This field is required.Laser, facials, peels, etc.
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Our consultations require a deposit of $100 in order to schedule. Your deposit covers the cost of the consultation appointment, and does not go towards your product purchase. Your deposit is due at the time of scheduling. Failure to complete your deposit within 24 hours of your request will result in your appointment request being declined. You can pay your deposit on the next slide, please contact us at appo initial to acknowledge *
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Consultation Deposit
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ORDER SUMMARY
Total costUSD
Non-Refundable Consultation DepositDeposit covers the entire cost of consultation. Deposit does not cover the cost of products that are assigned during consultation.
$100.00Edit
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Total cost $0.00
Consultation Deposit
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Signature* This field is required.I have read each of Live by Skin's policies and acknowledge that I understand them. If you cancel or reschedule your consultation with less than 48-hours' notice, your full deposit is forfeited and you will need to place another deposit to schedule another consultation.
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