Name
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First Name
Last Name
Email
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Phone Number
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Tell me a little bit about yourself and how long you've been dealing with acne:
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How would you describe your skin?
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What are your breakouts like? How frequent are they?
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Do you pick at your acne?
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What is your current stress level?
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Have you ever worked with an Esthetician before?
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If yes, how long ago and how frequently?
Have you previously had any skin treatments?
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If yes, please give a brief description
Do you have a current skincare regimen?
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If yes, what is your current regimen?
How often do you see a Dermatologist?
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Have you used or are you currently using any products that contain Retin-A/Retinol?
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Do you have any allergies, medical conditions or sensitivities that you know of?
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if so, please list them here:
Have you ever taken any antibiotics or used topicals to treat acne?
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Have you taken Accutane within the last 6 months?
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Are you taking any Birth Control, supplements, or any other medications?
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if so, please list them here:
Are you pregnant or breastfeeding?
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If needed are you willing to stop using any products in your current regimen once we begin your care?
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Are you local to Lewiston, New York?
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Where did you hear about me?
Expectations Agreement
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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.
Credibility Agreement
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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
