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.Home PhoneCell Phone*Cell Phone Service ProviderAddress 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 UsWebsiteSocial MediaInternetClient Referral NamePlease 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 you have used on your skin? Please describe Save and Continue Later Please list the following products you are using by brand/ name:CleanserTonerMoisturizerSerumSPFMakeup/FoundationConcealerPrimerNight time moisturizerAcne ProductsMaskShampoo & ConditionerHair Styling Products: Any and allWhat other treatments have you tried on your skin?Do you use fabric softener or dryer sheets?YesNoDo you pick at your skin?YesNoDo you work around chemicals, tar, oils or inks?YesNoOccupationWhich 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 Are you currently under stress?YesNoAt what age did your acne start?Are you under the care of a Dermatologist?If yes then please name.I am a client whoPrefers 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 both Save and Continue Later Are you pregnant or nursing?YesNoAre you using birth control?Please list name and dosageIf 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 submit photos of your acne affected areas so we can assess your skin. Pictures should be taken without makeup, in good light (daylight preferred), up close (fill the frame) and sharp/ in focus . It might feel uncomfortable to do this. However, it helps us get a better understanding of what's going on with your skin. For Virtual Clear Skin clients this will be beneficial for us should you need our help troubleshooting in the future. Thank you in advance! Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.