Acne Attack Consultation

Acne Attack Consultation

Please be as thorough as possible! Be sure to book an appointment if you have not done so already.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Birthday

MonthDayYear
Date
Email
example@example.com
Ethnicity
Medical History

Please be as thorough as possible!

Please fill in the below list if you have taken any of the below medications.

Rows	When	How long?	Medication Name
Antibiotics (Oral)
Antibiotics (Topical)
Accutane
Benzoyl Peroxide
Retin-A, Tazorac, Differin
Thyroid Medication
Blood Thinning Medications
ADD/ADHD Medications

Please list any other medications or drugs listed that you have used in the past 2 years and include when they were used, and for how long you used them (do not forget vitamins!):
Please check all that apply to your medical history:
Who is your Primary Care Physician?
Are you under a dermatologist's care? Please list their name.
Have you ever had a reaction to any skincare products? Do you have any known allergies?
Do you use birth control pills, shots, or an IUD? Please give the name and dosage if so.
Are you pregnant and/or nursing?
Have you had any other treatments in the past 90 days? Please describe if so.
Botox, fillers, and other invasive treatments have a required downtime post procedure. ADE is not responsible for scheduling around these. Please confirm with your other provider how long you must wait between treatments and schedule accordingly. My cancellation policy will be fully enforced.
Lifestyle Considerations

This section may feel a little weird, but there's no judgement! Please answer these honestly to help us find any hidden acne triggers.
Do you smoke or vape?
If yes, what do you smoke?
Do you use fabric softener?
If yes, what do you use?
Do you swim in a chlorinated pool often?
Do you work around chemicals, tars, oils, grease or inks?
Do you work night shift?
Rate your current stress level: (common stress triggers: job loss, new job,wedding, death in the family or close friend, graduation, long commute, heavily scheduled)
Do you get shaving irritation on your face?
If you shave your face at all, please tell me what razor you use.

How often do you consume the below foods?

Rows	Never	Once or Twice a Month	Once or Twice a Week	3 - 4 Times per Week	5 - 6 Times per Week	Daily	Multiple Times per Day
Fast Food
Processed Food
Salty Snacks
Milk/Yogurt
Cheese
Whey or Soy Protein (Powder or Shakes)
Peanut Butter
Peanuts
Sushi
Kelp and Seaweed
Miso Soup
Soy
Seafood

Have you ever used Face Reality Skincare products before?
If yes, are you still using them?
In detail, describe your current routine AM + PM.

Acne Treatment Consent Form

An acne treatment may consist of surface cleansing, mild chemical peels or steam and exfoliation, application of antibacterial serums, corrective serums, and extractions. Treatments take approximately 20 to 45 minutes to complete and are designed to balance, hydrate, extract acne impactions, and prepare the skin for the home care routine. Implements and equipment used in this facility are disposable or properly sterilized according to the State Board of Cosmetology regulations.
IMPORTANT: Please Read Carefully and Initial
I will not expose my skin to excessive sun before my appointment. If I am burnt, I understand we cannot perform in-clinic treatments nor can we recommend active products.
I will not have any other chemical peel of any kind , within 14 days of any treatment.
I will not have any facial waxing for 7 days prior to in-clinic treatment.
I have informed the clinic of all health problems of which I am aware, including herpessimplex/cold sores (we cannot perform any treatment with an active cold sore - please reschedule if this occurs).
I understand that to clear the skin of acne is best achieved through a series of treatments and consistency with the homecare product routine recommended by my Acne Expert. If I am a virtual client, I understand this may take more time due to not having in-clinic treatments.
I understand that I will probably not experience much visible peeling, flaking, discoloration orirritation following in-clinic procedures if I follow my home care instructions carefully.
WARNINGS: Please Read Carefully and Initial
I will avoid direct sunlight or tanning booths for at least 3 days following an in-clinic treatment.
Use of sunblock protection is especially necessary following all treatments, and daily use and reapplication is expected.
I understand picking my skin will prohibit healing and cause more issues. If I feel the urge to pick, I will apply a pimple patch.
Face Reality Skincare products are clinical-strength active formulas. Mild tingling sensations are possible with product application but should not be irritating. If I experience stinging andor irritation with any product, I will stop using the product and contact my Acne Expert for guidance.
RESCHEDULING GUIDELINES AND LATE POLICY: Please Read Carefully and Initial
A 24-hour rescheduling notice is required. We realize emergencies will happen and will be considered, but ADE reserves the right to charge a $75 fee for missed appointments without 24-hour notice. If you are more than 10 minutes late to any in-clinic treatment or virtual appointment, ADE cannot guarantee that we will be able to fit your appointment into the schedule and you may not be seen. If we cannot fit you into the schedule, there will be a $75 fee charged for the missed appointment.
I consent to photographs taken of my face to be used for monitoring treatment progress.
I consent to my photographs being posted for marketing and educational purposes.
Name of Client

First NameLast Name
Name of Guardian if Under 18

First NameLast Name
Today's Date

MonthDayYear
Date
Client or Guardian's Signature
Should be Empty:

Acne Attack Consultation

Medical History

Lifestyle Considerations

Acne Treatment Consent Form

IMPORTANT: Please Read Carefully and Initial

WARNINGS: Please Read Carefully and Initial

RESCHEDULING GUIDELINES AND LATE POLICY: Please Read Carefully and Initial