Face Reality Acne Bootcamp New Client Intake Form

Face Reality Acne Bootcamp New Client Intake Form

Ready to kick acne in the butt? Fill out this form and your esthetician will be in contact with you within 24-48 hours to discuss next steps and create your custom skincare routine.
All responses to questions are private and confidential, and used only by your esthetician at Trentuno Skin Studio for the benefit of assessing your acne type, knowledge of lifestyle factors, and creating your routine. Answers and client information is never sold or published.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you seeking in-person or virtual skincare treatment?*

In-personVirtual
Birthday*

MonthDayYear
Date
Please indicate if you have used any of the following medication’s or drugs listed below in the past two years:

Antibiotics (oral)Antibiotics (topical)AccutaneBenzoyl PeroxideRetin-ATretinoinDifferinTrazoracBlood Thinning MedsThyroid Meds
Please list any other medications or drugs that have been used in the past year if not on this list (if any):
Medical history (check all that apply):*

HerpesEczemaPsoriasisHepatitisCancerStaph Infection/MRSAHIV/AIDSThyroid ProblemsHormone ProblemsHysterectomyOvary(ies) RemovedPacemakerHemophiliaLupusAnemiaHigh Blood PressureDiabetesMetal Pins In BodyNone of the Above
Are you currently under a dermatologist or other physicians care?*
Have you ever had any reaction to any products or anything you have put on your face? If yes, what products?*
Do you have any known allergies to sulfur, aspirin, or latex?*
Do you smoke/vape?*

VapeSmokeNo, I do not.
Do you drink alcohol?*

Yes!No.I do occasionally...
Do you use fabric softener or fabric softener sheets in the dryer?*

YesNo
Do you often swim in a chlorinated pool?*

YesNo
Do you work around chemicals, tar, oils, grease, or inks?*

YesNo
Are you currently under a lot of stress? (Common stress triggers: job loss, new job, wedding, death in the family or close friend, graduation, long commute, heavily scheduled, etc.)*

Yes, I am.No, I am not.
For the girls: Do you use birth control pills, shots, or use an IUD?*

YesNo
If so, which do you use and what is the brand (if you know)? If you don’t use birth control, just put N/A.*
Are you pregnant or nursing?*

YesNo
If you shave your face, do you ever experience irritation?*

YesNoI don’t shave.
If you answered, yes, what type of razor do you use for shaving? (Double blade, triple blade, rotary, etc.)

DIET - Do you consume the following?*

	Very Often	Somewhat Often	Rarely
Fast Food
Processed Foods
Salty Snacks
Milk
Yogurt
Cheese
Peanut Butter
Whey
Soy
Peanuts
Sushi
Kelp and Seaweed
Miso
Vitamins/Supplements
Seafood
High Sugar Foods
Energy Drinks
Coffee
None of the Above

Have you ever used any Face Reality Skincare products before?*

YesNo
Current Skincare Routine:*

CleaserTonerSerumsMoisturizersSPFMasksTopical Acne MedicationExfoliants/ScrubsI don’t have a routine.
Please list what skincare products you use: (if you don’t have a routine, put N/A.)*
What other treatments have you done on your skin in the last 90 days?*

Chemical PeelsMicrodermabrasionMicroneedlingLaser Hair RemovalLaser Skin RejuvenationSkin Cancer RemovalFacial WaxingElectrolysisOtherNone of these
What skin type do you have?*

I am oily all over my face.I am oily only on my chin, nose, and forehead.I am dry and dehydrated.I feel dry and tight after I wash my face and/ or I have flaking in certain areas.I feel normal - no dryness or noticeable oil production.I’m not sure…
What are you on the Fitzpatrick scale?*

I - Very fair skin, prone to freckles, burns extremely easily.II - Fair/light skin, burns but may gradually tan.III - Light olive skin, burns with long sun exposure but generally tans easily.IV - Medium brown skin, burns with very long sun exposure, but tans easily.VI - Dark brown skin, burns only with extreme sun exposure but always tans.I’m not sure.
What type of acne are you currently experiencing?*

CongestionBlack headsWhiteheadsPimplesCystic and inflamed acneNodulesPost acne hyperpigmentationTexture but no active acneI’m not sure
Please upload a picture of your skin and areas of concern:

If you’re unable to upload photos, please text them to your esthetician at 704-793-8396.
Right side of face:

Cancelof
Left side of face:

Cancelof
Forehead:

Cancelof
Chin:

Cancelof
Full face looking straight ahead:

Cancelof
Liability Waiver
I (client name), agree to having to undergo this treatment/procedure after having the treatment details and nature of the treatment along with risks and hazards involved by qualified and licensed esthetician. Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications. I also recognize there are no guaranteed results and that independent results are dependent upon age, skin condition, and lifestyle factors and that there is the possibility I may require further treatments of the treated areas to obtain the expected results at an additional cost. I have read and understand the post-treatment aftercare instructions. I understand how important it is to follow all aftercare instructions given to me. I have also, to the best of my knowledge given an accurate account of my medical history, including all known allergies or prescription drugs or products I am currently ingesting or using topically. I understand and agree to the after-care instructions, provided by the licensed esthetician. I realize and accept the consequences of failure to adhere to these instructions may cause no to little results obtained.
Signature*

Clear
Hold Harmless Waiver
I have read and understand this agreement and all information detailed above. I understand the treatment and accept the risks associated with it. I acknowledge that I have been informed of the risks associated with this treatment and have had the opportunity to ask my provider any question regarding this. I understand how important it is to follow all instructions given to me for post-treatment or suggested home product/post - treatment care, I will consult the esthetician immediately if any adverse reactions occur. I have also, to the best of my knowledge given an accurate account of my medical history, including all known allergies or prescription drugs or products I am currently taking. I also agree to defend, indemnify and hold harmless Victoria Vance, LME at Trentuno Skin Studio, from any and all reactions, burns, claims, actions, expenses, damages, injuries, liabilities, including reasonable attorneys fees which might be asserted against them as a result of my having any procedure performed, or my purchase of products.
Signature*

Clear
Please verify that you are human*
Should be Empty:

Face Reality Acne Bootcamp New Client Intake Form

Please upload a picture of your skin and areas of concern:

Liability Waiver

Hold Harmless Waiver