Virtual Consultation Form Name * First Name Last Name Email * Phone (###) ### #### What is your current skincare routine? Please include AM/PM and the brand of products being used. * How long have you been dealing with acne? * LESS THAN A YEAR 1-2 YEARS 3+ YEARS Which of the following describes your skin? Dry Oily Combination Sensitive/Reactive I’ve been diagnosed with Rosacea Describe your acne, check all that apply. * Blackheads Whiteheads Cystic Hormonal Pustules/Papules Do you get irritated easily from skincare products? * Yes No If yes, please explain any experiences or allergic reactions. How often are you experiencing breakouts? * Often (I always have an active breakout) A few times a month Once a month Do you tend to pop or pick your acne? * Yes No Do you experience a stinging sensation when applying your current skincare? * Yes No Do you take any supplements such as multivitamins or hair and nail growth supplements? * Yes No If yes please share below which ones you are currently taking. Are you currently taking birth control? * Yes No If yes, please list which birth control (name) you are taking. Any other medications, especially those prescribed by a dermatologist (accutane, clindamycin, spironolactone etc.) ? * Yes No If yes, please specify. Do you exercise regularly? * Yes No Do you consume protein powder, pre-workout, or energy drinks? * Yes No Are you pregnant, nursing, or plan to become pregnant soon? * Yes No Do you smoke nicotine or marijuana? * Yes No Do you consume alcohol? * Yes, occasionally Yes, rarely No Do you work in an outdoor environment (ex. lifeguard, construction)? * Yes No Any other important information you want to share? How did you hear about us? Word of Mouth Facebook Instagram Google Other Thank you! Our team will be in touch soon.
