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Acne Review Form

Filling out this form will help us determine your unique acne type and skin sensitivity.

Please select who will be participating...
AdultMinor
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First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information
Gender*

Age:

At what age did you start to break out?
How many new pimples do you get each month?*
When you get the breakouts, do you mostly get inflamed, cystic pimples or small little bumps under the skin?*
How does your skin feel during the day?*
How often do you get new pimples?*
On what part of the face acne is located? Check any that apply... *
Forehead
Cheeks
Chin
Hairline
Nose
Jaw line
I don't have facial acne
On what part of the body acne is located? Check any that apply... *
Chest
Neck
Shoulders
Back
I don't have body acne
Is your skin sensitive?*
How does your acne feel?*
Do you pick at your skin?*
Do you have any scarring? Check any that apply...
Yes
No
Red marks
Brown spots, pigmentation
Ice pick/ indentation scarring from previous cyst
Have you taken Accutane in the last six months?*
What are you most concerned about your skin? Check any that apply... *
Acne
Scarring
Pigmentation, dark spots
Aging, fine lines, wrinkles
Sensitivity, redness
To much oil production

After completing this questionnaire make sure to email us photos of your face or body. 

When taking photos of your face please take one left side shot, one right side shot and one headshot/selfie. Please, email the photos to info@envisionacnecenter.com with the subject line Acne Type Photos and your Name. 

First Participant's Signature*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Gender*

Age:

At what age did you start to break out?
How many new pimples do you get each month?*
When you get the breakouts, do you mostly get inflamed, cystic pimples or small little bumps under the skin?*
How does your skin feel during the day?*
How often do you get new pimples?*
On what part of the face acne is located? Check any that apply... *
Forehead
Cheeks
Chin
Hairline
Nose
Jaw line
I don't have facial acne
On what part of the body acne is located? Check any that apply... *
Chest
Neck
Shoulders
Back
I don't have body acne
Is your skin sensitive?*
How does your acne feel?*
Do you pick at your skin?*
Do you have any scarring? Check any that apply...
Yes
No
Red marks
Brown spots, pigmentation
Ice pick/ indentation scarring from previous cyst
Have you taken Accutane in the last six months?*
What are you most concerned about your skin? Check any that apply... *
Acne
Scarring
Pigmentation, dark spots
Aging, fine lines, wrinkles
Sensitivity, redness
To much oil production

After completing this questionnaire make sure to email us photos of your face or body. 

When taking photos of your face please take one left side shot, one right side shot and one headshot/selfie. Please, email the photos to info@envisionacnecenter.com with the subject line Acne Type Photos and your Name. 

Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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