Clone of Online Acne Consultation Form

Teen Online Acne Bootcamp Intake

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 four photos

-One from each side

-One straight on

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

Area CodePhone Number
Date of Birth*

DayMonthYear
Age
E-mail Address*
Ethnicity *
Prescribed and Over the Counter Medications (Past and Present Use)
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? *

YesNo
Are you currently nursing? *

YesNo
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? *

YesNo
If so, what was the product and what kind of reaction did you experience?
Check if you are allergic to:*

SulphurAspirinShellfishNone
What are your skin care concerns?*

Age SpotsBlackheadsBroken CapillariesBumps or Pebble Under the SkinCystsDark SpotsDehydrated SkinDry, Flaky SkinFine Lines/WrinklesMiliaOily SkinPimples/PustulesRazor BumpsShaving IrritationOther
What is your general Skin Type? *

OilyCombinationNormalDryI dont know
Lifestyle Questions
Check box if Yes:

Have you been diagnosed with rosacea?Do you smoke? Marijuana or TobaccoAre you currently under stress ?
Do you use Fabric Softener or Dryer Sheets?*

YesNo
Do you regularly eat or ingest:*

KelpSeaweedSushiSaltFast foodmilk and/or cheesepeanuts or peanut buttersupplements, vitamins, or drink powdersprotein bars such as Cliff BarsProtein shakes or whey proteinNone of these apply
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.*

Yes
Time to Submit Photos
Please upload your FRONT FACING photo here.*

Browse Files

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Please upload your 2 SIDE photos here.*

Browse Files

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Please upload your 2 PROBLEM AREA photos here.*

Browse Files

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PAYMENT *

Online Acne Bootcamp Fee$224.25

**Originally $299- on sale for Cyber Monday** We will contact you within 24 hours after receiving payment to schedule your first Zoom call. All documents will be sent at this time.

Total $0.00

Payment Methods

Credit Card

Apple Pay

Google Pay

Cash App Pay

ACH Bank Transfer

Afterpay

**Important. Please Read First**

After submitting the form, an invoice will be sent to the email address you provided above. The consultation process will begin once payment has been made. We will call to schedule within 24 hours.
Should be Empty:

Teen Online Acne Bootcamp Intake

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

Current Skin Care Regimen

Lifestyle Questions

Time to Submit Photos

Payment Methods