Name *

First Name

Last Name

What is your Main Skin Concern? *

Dry, Dull Skin

Acne

Acne Scarring

Hyperpigmentation, Sun Damage, Dark Spots

Aging, Finelines + Wrinkles

Redness, Sensitive Skin

Texture

Uneven Skin Tone

Other

How would you describe your skin? *

Oily

Dry

Combination

Sensitive

Normal

What is your current stress level? *

Average

High

Low

Have you ever worked with an Esthetician before? *

Yes

No

Have you previously had any skin treatments? *

Yes

No

Do you have a current skincare regimen? *

Yes

No

Kinda?

How often do you see a Dermatologist? *

Regularly

Sometimes

Never

Have you used or are you currently using any products that contain Retin-A/Retinol? *

Yes I am now

Yes, I have before

No

I am Unsure

Do you have any allergies, medical conditions or sensitivities that you know of? *

Yes

No

Have you ever taken any antibiotics or used topicals to treat acne? *

Yes

No

Are you taking any Birth Control, supplements, or any other medications? *

Yes

No

Are you pregnant or breastfeeding? *

Yes

No

If needed are you willing to stop using any products in your current regimen once we begin your care? *

Yes

No

Are you local to Lewiston, New York? *

Yes

No

Expectations Agreement *

Clearing and managing acne is a process that can take time, patience, commitment, and sometimes major lifestyle changes. By selecting “I Understand”, you acknowledge the depth of the process and agree to work with me as a team with no timeline expectations.

I Understand

I would like to chat about this

Credibility Agreement *

By selecting “I Understand”, you acknowledge that I am a Licensed Esthetician and skincare professional with your best interests in mind at all times. You also understand that steering from any guidance you receive may lead to unwanted, delayed, or an altogether lack of results

I Understand

I would like to chat about this

How much are you expecting to invest for your home care routine? Our goal is to make sure your results and home care are easily obtainable for you. *

$150-$250

$250-$350

I am willing to invest whatever tit takes to target my skins concerns with result driven products

I would like to make slight adjustments to my routine, and understand that using products not recommend may alter my results!

I agree to send updated skin photos upon completion to the listed email or number, and understand that a routine cannot be created without photo submission *

I understand