Agent Rx + Skin History Form

Our virtual skin history form will gather all the necessary details to make our time together the most impactful.

➕Be prepared to take pictures of your skin with your phone and have your skin care and supplements/medications ready to enter below.

➕The more information we have from you the better we can understand your skin and recommend the right options for you.

➕We recommend nearing the completion of your current skincare items before booking your consultation. This way, you'll be all set to embrace a fresh, comprehensive routine tailored just for you.

We are looking forward to guiding you on your new skin journey!
Name:*

First Last
E-mail:*
We will never sell your email to a third party.
Mobile:*
How did you hear about Agent Rx?*
Type a name if referred by a current client.
Your Skin Journey
How would you describe your skin type?*

DrySensitiveCombinationBalancedOily
Which skin conditions would you like to improve?*

AcneAcne MarksDry SkinFirmnessGeneral Skin HealthLines & WrinklesOily SkinPigmentationRednessRosaceaSensitive SkinTextureOther
What areas would you like to improve?*

FaceNeckChestHandsOther
What's the most important goal for your skin?
Your Current Daily Skin Routine

Please list the product names and brands. This step is crucial to identify any products that may not be a good fit for your skin.

	Morning	Evening
Cleanser
Toner/Mist
Serums
Eye Cream
Moisturizer/ Oils
Sunscreen
Prescription Topicals (Retin A, Tretinoin, etc.)
Exfoliation: Peels, Scrubs, etc.
Devices: Brushes/Rollers
Makeup Foundation

How often do you exfoliate?*

Daily2-3x per weekOnce per weekOther
Please list any additional topical products you are using:
Your Budget
Some may shy away from discussing this topic due to concerns about appearing rude or elitist, we believe in open communication and complete transparency when it comes to setting expectations.

At Agent Rx, we understand that higher prices don't always equate to superior results. While there are instances where cost correlates with effectiveness, it's not always the case. With years of experience and thorough testing, we have personally tried and evaluated every product on our shelves, both on ourselves and on thousands of satisfied clients.

Our primary objective is to ensure that you achieve noticeable results while also maintaining the affordability of the products necessary for maintaining healthy skin. We prioritize your skincare journey and strive to provide you with the best possible outcomes without unnecessary expenses.

Generally each product in your daily regimen will last approximately 2-3 months.
What is your monthly budget for skin care products?

$100-$200$200-$300$300-$400$400 +
Your Medical History
Have you experienced a reaction to a topical product?*

YesNo
If yes, please list the details:
Do you have any Food Allergies or Sensitivities?*

YesNo
If yes, please list:*
Are you taking any supplements or herbs?*
It is very important we know all your supplements especially for Acne.
Are you taking any prescription medications?
It is very important we know all your medications.
Are you pregnant or breastfeeding?*

YesNo
Do you have an implanted IUD?*

YesNo
If yes, list type/brand:
Your Lifestyle
What is your occupation?*
Student, Chef, Tech, Nurse, etc.
Do you live or frequently travel to high elevation areas?*

YesNo
Do you participate in outdoor sports or leisure outdoor activities?*

YesNo
If yes, please list:
Beach, Tennis, Swimming, Golf, Ski, etc.
How often do you smoke, vape or chew nicotine?*

DailyFew times a weekFew times a monthNever
Pictures

Use your mobile phone
How to take a clear picture of your skin.
1. Stand about 2-3 feet away from a light source. A window with natural light is best. If it is night time you can stand in front of an artifical light source. Make sure the light is evenly illuminating your skin without casting shadows over your skin. Do not stand with your back facing the light source.
2. Remove glasses. Pull back hair off your face.
3. Hold phone about 12" from face. Snap picture.
4. See example pics below for correct and incorrect pictures.
  1. Light source is BEHIND. Incorrect ❌
  2. Light source is in FRONT. Correct! ✅
  3. Light source is BEHIND. Incorrect ❌
  4. Light source is in FRONT. Correct! ✅
Picture 1 - Front facing.

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Picture 2 - Left Side: Stay in the same place, turn head to the right.

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Picture 3 - Right Side: Stay in the same place turn head to the left.

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Picture 3 - Other Area like hands, chest, back etc. make sure light position is the same as above.

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I agree to the processing and storage of personal data by Skin Clinical SF, Inc. DBA Agent Rx. I understand the information I provide is only used to correctly analyze my skin and avoid possible reactions. My information is confidential and is NOT sold to third parties.*

I agree.
I grant my permission to Skin Clinical SF, Inc. to use my progress photos for marketing in emails or social media posts.*

I agree.I disagree.
Date*

MonthDayYear
Signature*
Should be Empty:

Your Skin Journey

Your Current Daily Skin Routine

Your Budget

Your Medical History

Your Lifestyle

Pictures