Virtual 1:1 Acne Coaching Form

  • Virtual Acne Coaching Form

    Please be very specific and answer all questions thoroughly. These questions will be what determines the plan to get you clear and if you are a good candidate for the program. You will be contacted via email with your custom regimen once your submission has been reviewed by your acne expert. Commonly asked questions regarding Acne Coaching can be found on the FAQ page via www.aestheticsbytay.com. Thank you!

  • Intake Information

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  • Date of Birth *
     - -
  • Today’s Date*
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  • Medications/allergies/surgeries

  • Do you have regular periods?*

  • Are you going through menopause?*

  • Skin History

  • What do you consider your skin type?*
  • How often do you do a skincare routine?*

  • Product Usage

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  • How often do you wear makeup products?*
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  • Do you sleep with hair pulled back or down?*
  • Do you wear spf every day?*

  • Contraindications

  • Please check all that apply.*

  • Lifestyle

    Diet, stress, sleep, etc.
  • Do you smoke/vape?*
  • Do you use fabric softener or dryer sheets?*
  • Do you swim in a chlorinated pool?*
  • What is your stress level right now?*
  • Do you use a tanning bed? Please note that we are unable to accept clients that lay in tanning beds, as this is a contraindication to your skincare regimen and treatments.*
  • Do you squeeze/pop/self extract breakouts? (be honest lol!)*
  • If yes to above question, do you squeeze/pick...*
  • How do you extract/pick at breakouts?*

  • Check the statement that applies most to you*

  • Mark any statement you feel that applies to you*
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  • How hopeful do you feel about starting acne bootcamp?*

  • By SUBMITTING THIS FORM, you agree to the following:
    1) I understand that the therapist or esthetician does not diagnose illnesses or injuries, or prescribe medications.
    2) I have clearance from my physician to receive acne treatments.
    3) I understand the risks associated with acne treatments include, but are not limited to:
    • Superficial redness
    • dyness/flaking
    • irritation 
    4) I understand the importance of informing my aesthetician of all medical
    conditions and medications I am taking, and to let the aesthetician know
    about any changes to these. I understand that there may be additional risks
    based on my physical condition.
    5) I understand that it is my responsibility to inform my esthetician of any discomfort I may feel during the session so she may adjust
    accordingly.
    6) I understand that I or the esthetician may terminate the session at any
    time. 
    I, therefore, release Aesthetics by Tay and the individual esthetician from all liability concerning these injuries that may occur during the session.

    POLICIES:

    You must cancel/reschedule within 24 hours or you are charged 50% of your service fee. No exceptions.

    No call - No shows are charged 100% of their service. No exceptions.

    If you need to reschedule or cancel, please click the link in your confirmation text or email and it will prompt you to do so.

    When you book an appointment, you check the box that states you agree to these policies.

    Please do not bring guests to your appointment, unless approved otherwise. This includes children.

    Location: 151 WENDOVER DRIVE, Kingsport TN 37663. Please arrive ON TIME, not late or early.

    Please DO NOT wear makeup to your appointment as this takes away from the full time of your service.

    Thank you!

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