Mixi Acne Bootcamp Intake Form
Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Please list your full skincare routine below.
Please list your full makeup routine below.
What is your Gender?
*
Please Select
Male
Female
Other (Please specify...)
Other
How did you hear about Mixi Acne Bootcamp ?
*
Please Select
Website
Instagram
Facebook
Family/Friend
Referral (Please specify...)
Referral
Sign below to show your agreement:
The consult will provide information and guidance about health factors within my own control: my diet, nutrition, and lifestyle. I understand that DermaLab’s esthetician and health coach Bailee is not a medical physician- does not dispense medical advice, nor diagnose or treat any medical condition, but will provide nutritional support and acne education. She will provide education to enhance my knowledge of skin through the use of whole foods, dietary supplements, and skincare.
Signature
*
Back
Next
Health Information
List your Skin Concerns (Acne, Pigment, Dullness etc) in order of importance to you:
Rows
Skin Concern
1
2
3
Do you suspect or been diagnosed with any gut health issues, hormone issues, or anything of relevance to your skin health?
What treatments have you tried for your skin concerns and did they help?
Allergies and SensitivitiesÂ
List all allergies to medications, environment, and food:
Supplements and Medications
List all that you are currently taking and for how long:
Nutritional Health
Do you eat any of the following as a part of your regular diet?
Dairy (Milk, cheese, cottage cheese, yogurt)
Sugar
Alcohol
Coffee
Energy drinks
Peanut butter
Soy products (Soy milk, tofu, etc)
Gluten (Wheat, barley, and rye products)
Eggs
How many ounces of water do you drink per day? (Rough amount)
Back
Next
Continue
Continue
Should be Empty: