Acne

1

Please enter a promo code if you have one (Optional)

2

What is this consult for

Acne

Scarring

Skin Brightening/ Dark Spots

5

Please Specify:

6

Please take a photo of the affected area

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

7

What is your skin type?

Oily

Sensitive

Dry

Combination

8

Have you noticed any triggers that make your condition worse?

Stress

Certain foods

Menstrual cycle

Other

9

What makes your acne worse?

10

What age did you first start experiencing acne?

11

Have you been diagnosed with hormonal imbalance?

YESNO

12

Do you have dark spots or uneven skin tone in the area(s) you'd like to treat? (Hyperpigmentation)

YESNO

13

Are you currently treating your acne?

YESNO

14

If you are currently treating your acne, is it working well? (Please explain)

16

Have you taken any of the following steroids in the past 6 months?

Prednisone

Cortisone creams (For acne)

Anabolic Steroids

None

17

On a scale of 0-10 how significantly does your acne impact your self-esteem (0=not at all, 10=Very Badly)

18

Do you prefer topical treatments, oral medications, or a combination of both?

Topical treatments

Oral medications

Both

19

Do you have any concerns about potential side effects of acne treatments?

20

Is there anything else you would like to share with the healthcare team?

21

Allergies?

YESNO

22

What is your allergy?

23

Are you currently taking any medications, vitamins, herbs, or supplements?

YESNO

24

Please list your medications, vitamins, herbs, and supplements here:(Name, Strength, Regimen)

25

Do you have any medical conditions?

YESNO

26

Please list your medical conditions here:(Name, How long you've had the condition)

27

Terms and Conditions* This field is required.

28

gtm_debug

29

fbclid

30

gclid

31

utm_term

32

utm_content

33

utm_campaign

34

utm_medium

35

utm_source

36

_ga_cid