Adult Online Acne Bootcamp Intake Form

Prescribed and Over the Counter Medications (Past and Present Use)
Virtual Consultation

For Clients Who Are Not Local To Our Physical Office In Cary NC
STEP ONE:

Take Photos of Your Skin Before Taking the Quiz!

Pictures taken with a smartphone are fine; you will need to upload them to this intake form at the end of the questionnaire.

Instructions for taking photos

-Do not use flash

-Make sure that your pictures are not fuzzy or blurry

-Take five photos

-One straight on

-One from each side

-Two of your most problematic areas
Full Name
Gender
Phone Number

Area CodePhone Number
Date of Birth

DayMonthYear
Age
E-mail Address
Ethnicity
Choose your consultation
Please list any topical or internal medications that you are currently using.
Please list any internal or topical acne medications that you have used. Please explain when and for how long.
Please list all supplements, vitamins, energy bars, protein drinks that you take.
Are you using birth control? If so, what kind?
Do you have any health conditions or medications that you are taking?
Are you currently pregnant?
Are you currently nursing?
Current Skin Care Regimen
What is your current AM regimen? Please be specific and include names of products.
What is your current evening routine? Please be specific.
Are you using a daily SPF? If so, what kind?
Are you using foundation or blush? If so, what kind?
Please list any additional products that you use including peels, masks, enzymes and/or weekly treatments.
How long have you been on your current regimen.
Please list the products that you are running low on and/or you want to replace.
Do you shave your face? If so, what kind of razor do you use? Do you use shaving products? If so, what kind?
Have you ever had bad or allergic reaction to anything you have ever put on your face?
If so, what was the product and what kind of reaction did you experience?
Check if you are allergic to:
What are your skin care concerns?

Other
What is your general Skin Type?
Lifestyle Questions
Check box if Yes:
Do you use Fabric Softener or Dryer Sheets?
Do you regularly eat or ingest:
I acknowledge that this quiz does not come with acne coaching. I must purchase an Acne Bootcamp Bundle in order to receive acne coaching. This form is only the consultation.
Time to Submit Photos
Please upload your FRONT FACING photo here.

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Please upload your 2 SIDE photos here.

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Please upload your 2 PROBLEM AREA photos here.

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**Important. Please Read First**

After you submit, you will go straight to our secure checkout to pay your consultation fee. Your consultation begins once payment is received. Email clients receive a detailed outline of their skin type and concerns, product recommendations and treatment plan within 24 hours. FaceTime clients will be contacted within 24 hours to schedule.
Should be Empty:

Prescribed and Over the Counter Medications (Past and Present Use)

Virtual Consultation

Current Skin Care Regimen

Lifestyle Questions

Time to Submit Photos