Existing Customer Check-In

Long Distance Client or local clients who can’t come to the office every 2 weeks. Please fill out this form to better help us coach you to clear skin.

NOTE: Important! If any product stings or burns, please wash it off and contact us. This only means you are too dry and we need to adjust your home-care.

Today's Date*
MM slash DD slash YYYY

Full Name*
First Last
Email*

Phone*
How long have you been on our program?*

Which Acne Specialist do you work most closely with?
Are you still getting new breakouts?*
Is your skin more clear than when you started?*
Have you stopped using our products for any length of time?
If you answered yes to the above question, how long have you not used your products and which ones have you not been using?
How is your diet? Are you eating dairy, peanuts, whey/ soy protein powders, shakes, or bars? Have you limited sodium?*
Do you pick at your skin or try to pop pimples yourself?*
Females: What makeup are you wearing? Please list any and all
How many times per week have you been UNABLE to do your morning routine?*
How many times per week have you been UNABLE to do your evening routine?*
Write our your routine step-by-step (exactly as you apply them) morning AND evening. It is crucial that we know every step, please fill this out thoroughly even if you do everything as you're instructed. Thank you!*
Have you added any products to your skincare regimen that have not been purchased from us? Please list any and all below.
Please list any challenges you are having with the program so we can best support/ guide you.*
Are any products stinging or burning? If so, which one(s)?*
How is your skin feeling?*
I am currently playing sports.*
If yes, which sport?

Please list any new medications, vitamins or supplements you have started.*
Upload Photos*
Please take photos without makeup, preferably in daylight, without a flash, and have someone take them for you if possible. Make sure they are clear, unfiltered and in focus. This will better help us see how your skin is doing. You can upload multiple photos here and please use the larger file size your camera provides (typically 1 to 3 MB).

Include a right side, left side, and a front view please.

Drop files here or

Accepted file types: jpg, jpeg, png, gif, Max. file size: 256 MB.

I need to purchase products.*
Additional Questions/ Comments:
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Friday	Closed
Saturday	Closed
Sunday	Closed