Intake Form 1 2 3 Name* First Last What do you prefer to be called? -- Email* Please give us the email address you check most often. We will never sell your email or spam.What is the best number to reach you?*Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Birthdate* How Did You Hear About UsA FriendGoogleInstagramFacebookYoutubeModern Luxury Wedding MaganizeDecatur LivingIf it was a friend, who can we thank for referring you?Please list any any all medications you are taking , prescribed or recreational:*Please choose any/ all health conditions you have been diagnosed with:* Anemia Lupus AIDS/HIV Blood Clots/Stroke Hemophilia Cancer Eczema Hepatitis Herpes Simplex/Cold Sores High Blood Pressure Hormone Problems Hysterectomy/ Ovaries Removed PCOS Staph Infection/MRSA Thyroid Disease None Are you taking any vitamins or supplements? Please list all.*Have you ever had an allergic reaction to any products (i.e. Benzoyl Peroxide) you have used on your skin? Please describe* Save and Continue Later Please list the following products you are using by brand/ name:Makeup/FoundationConcealerPrimerAcne Products (if any)*Shampoo & ConditionerHair Styling Products: Any and allWhat other treatments have you tried on your skin?*What laundry detergent do you use?*Do you use fabric softener or dryer sheets?*YesNoDo you pick at your skin?*YesNoDo you work around chemicals, tar, oils or inks?*YesNoOccupationAbout how many (8 oz.) glasses of water do you drink each day?What is your average alcohol consumption?*What is your average caffeine consumption?*Which of these foods do you consume regularly?* Peanuts/ Peanut Butter Fast Foods Dairy: Milk/ Cheese/ Yogurt/ Ice Cream Green Juices/ Smoothies Protein Shakes/ Bars/ Powders Salt/ Salty Snacks Seaweed/ Kelp/ Sushi Sports Drinks I don't eat any of these foods Have you been under a lot of stress lately?*YesNoAt what age did your acne start?Are you under the care of a Dermatologist? (If yes, please name)*I am a client who*Prefers In-office treatments. I want to work directly with my Acne Specialist.Prefers the Virtual Clear Skin Program. I'm a self starter.Probably a combination of bothNot Sure Save and Continue Later Women, are you pregnant or nursing? (Men choose "No")*YesNoAre you using birth control?*Please list name and dosageMen, if you shave your acne affected areas, what do you use? (Razor, clippers, electric razor, etc.)* Please list brands including shaving cream How can we best help you?For clients who choose to work with us in the officeWhat are your skin care goals?Why do you want clear skin? What would it mean to you?What have you tried in the past that has not worked for you? What are your concerns?*What would keep you from following your prescribed protocol/regimen?*Are you willing to follow our recommendations? Why?*Are you willing to make changes based on our recommendations (i.e. diet, lifestyle, etc) to achieve results? Please explain.*On a scale of 1-10, 10 being the most, How much do you want to get clear?On a scale of 1-10, 10 being I'll do anything, How willing are you to DO everything it takes to get clear?*How can we best support you through your journey to clear skin?Upload Photos of your acne affected area(s)* Drop files here or Please upload photos of your acne affected area(s). These photos will not be used for anything other than preliminary assessment unless you permit otherwise. Pictures should be taken in good light (daylight preferred), up close (fill the frame) and sharp/ in focus, and without makeup. Thank you in advance! Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.