Skin Quiz: Kit Assessment Form

Skin Quiz - Kit Assessment Form

Please take a quick second to answer the following questions so we can provide you with the best recommendation. We will review the information you provide here and let you know which type of our Do-It-Yourself Acne Rescue Kit will be the best for you. You must be 18 or older to submit this form. If you are a minor, please have your parent or responsible party submit this form.
Today's Date*

MonthDayYear
Date
Name*

First NameLast Name
If you are a minor, name of your parent.

First NameLast Name
Email (If you are a minor, please provide your parent's email.)*
example@example.com
Where do you live? (State / Country)
Date of birth*

MonthDayYear
Date
What skin care products have you been using? Please list everything you have used and are currently using in the last 2 months.*
YesNo
Have you used any prescribed topical medications in the last 6 month? If so, what are they? If none, please write N/A.*
*If you are using any topical medications, we require that you discontinue usage at least 2 weeks prior to beginning usage of our Acne Rescue Kit. If you are on Accutane, we require that you discontinue its use at least 4 months prior to usage.
Are you allergic to anything? Please list all. If none, please write N/A. *
Very OilyOilyCombination - T-Zone is oily but not cheeks.Slightly DryVery Dry
ForeheadNoseCheeksChinJawlineBackChestHair lineOther
BlackheadsWhiteheadsPimples/PustulesCystsDark Spots/Acne Scars/ HyperpicmentationsBroken CapillariesSaving IrritationIngrown HairLazer BumpsSensitive SkinRosaceapsoriasis/EczemaOther
With sun exposure, your skin... *
What is your ethnic background? *
Please be specific.
YesNoMale
Is there anything else you would like us to know? Any other information that will be helpful for us to help you?
Any health issues? Medications you are taking? Allergy?
Do you have any questions for us?
Let us know what you would like to know.
Very Important! Please upload pictures of your acne area from 3 different angles. Example: For face acne, please provide images of the right, front, and left sides of your face. Please include the whole face, not just the problem areas. For back acne, please provide images of the entire back, including upper shoulders, and neck area. * If you fail to submit these images in good lighting, we will ask you to resubmit this form again. Your face must be clean. Makeup must be removed.
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Thank you for taking the time to fill out this form. One of our Acne Specialists will respond within 72 business hours with the recommendation.
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Skin Quiz - Kit Assessment Form