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Virtual Acne Consult Form

The below form will collect information that will help develop a custom treatment plan for your conditions and needs. All of the information you provide is confidential and used only for the purpose of treating your acne.                           

 

 

 

First New Client Name

First Name*

Middle Name

Last Name*

Phone*
First New Client Date of Birth*
First New Client Signature*
Second New Client Name

First Name*

Middle Name

Last Name*
Second New Client Date of Birth*
Third New Client Name

First Name*

Middle Name

Last Name*
Third New Client Date of Birth*
Fourth New Client Name

First Name*

Middle Name

Last Name*
Fourth New Client Date of Birth*
Fifth New Client Name

First Name*

Middle Name

Last Name*
Fifth New Client Date of Birth*
Sixth New Client Name

First Name*

Middle Name

Last Name*
Sixth New Client Date of Birth*
Seventh New Client Name

First Name*

Middle Name

Last Name*
Seventh New Client Date of Birth*
Eighth New Client Name

First Name*

Middle Name

Last Name*
Eighth New Client Date of Birth*
Ninth New Client Name

First Name*

Middle Name

Last Name*
Ninth New Client Date of Birth*
Tenth New Client Name

First Name*

Middle Name

Last Name*
Tenth New Client Date of Birth*
New Client Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
skinfortellc@gmail.com
How did you heard about E SKIN Forte?
How did you heard about E SKIN Forte?*
Google
Yelp
Facebook
Another Esthetician
Face Reality Acne Specialist referral
Instagram
Friend/ Family

Referred by:
Acne Client Questionnaire: l

* Important questions about your acne.


At what age did you begin having acne?
Have you ever been diagnosed with Rosacea?*
No
Yes
Race/Ethnicity*
What is your primary acne or skin concern(s)?
PIH/Acne scars
Cystic
Uneven skintone
Blackheads
Whiteheads
Pustules
Razor Bumps
Shaving Irritation
Which of the following best describes your skin type.*
Dehydrated
Dry
Normal
Oily
Very Dry/ Flaky
Combination Oily/Dry
Sensitive
What are your top areas of concern(s)
Forhead
Hairline
Cheeks
Chin
Nose
Jawline
Neck
Back
Shoulder
Chest
Back of neck
Check if you ever had allergic reactions to anything you have ever put on your skin or do you have any food allergies? List what you were allergic to:
SULFUR
ASPIRIN
LATEX
BENZOIL PEROXIDE

if "others" please list names.
What treatment procedures have you had on your skin currently or in the past?
Corrective Peels
Mircodermabrasion
Laser Hair Removal
Facial Waxing
Facial Sugaring
Electrolysis
Plastic Surgery
Skin Cancer Removal
ll

*Important questions about your Lifestyle:

Do you smoke cigarettes?*
No
Yes
Do you use fabric softener or dryer sheets?*
No
Yes
Do you have a tendencies to pick your skin?*
No
Yes
Do you swim?*
No
Yes
Do you play any musical instruments?*
No
Yes
Do you play sports that require you to wear head/body gears?*
No
Yes

if so, what kind of sport.
Do you often do hot showers?*
No
Yes
Are you vegetarian?*
No
Yes
Do you feel you have an excessive amount of stress?*
No
Yes

Rate your stress level of a scale of 1 - 10 ( 1 being low and 10 high) *
Do you practice any relaxation techniques?*
No
Yes

If Yes, which one and how often a week?

How many hours of sleep do you get per night on average? *

What's your profession? *
Does you job requires you to be out in the field?*
No
Yes

Any other activities do you do? *
lll

*Important questions about your Medical History:

Are you currently under the care of Dermatologist?*
No
Yes

If you are under medical care please provide your Doctor's name:
Prescribed medications, over the counter products and procedures for ACNE (Past and Present)
Accutane/Isotretinoin
Aldactone/Spironolactone
Oral Tretracycline
Oral Doxycycline
Oral Minocycline
Topical Erythromycin
Topical Clindamycin
Aczone (Dapsone)
Benzoil Peroxide
Benzamycin (BPO + Erythromycin)
BenzaClin/Duac/Acanya/Onexton/ (BPO + Clindamycin)
Birth Conrol Pills for acne (Ortho-Tricyclen/Yaz)
Tazorac/ Avage Gel
Tazorac/ Avage Cream
Atralin/Avita/Retin-A/Tretinoin Gel
Avita/ Retin-A/ Tretinoin CREAM
Ziana (Tretinoin + Clindamycin)
Differin
EpiDuo (Differin+ BPO)
Sulfur
Finacea/Azelex/Metrogel/Mirvaso
Cortisone Injections (Target Inflammation)
Cleocin-T
E-Mycin-T
Thyroid Medication
Minosine
Copaxone
Testosterone
Progesterone
Disufuram
Dilantin
Lithium
Quinine
Isoniazid
Immuran
Danzol
Cocaine/ Speed
Marijuana
Steroids
"other"
Conditions you have had in the past two years? *
Anemia
Cancer
Depo Provera Shots
Eczema
Epilepsy
HIV Positive /AIDS
Hearing Devices
Hemophilia
Hepatitis
Herpes Simplex/ Cold Sores
High blood Pressure
Hormone Problem
Hysterectomy/ Ovary(ies) removed
Lupus
Metal Pins/ Brackets in the body
Nursing/ Breastfeeding
Pregnancy
PCOS
Pacemaker
Psoriasis
Recent Surgery
Staph Infection
Thrombosis/ Blood clot strokes
Thyroid Problem
N/A
lV

*Important questions about your eating habits and diet:

Do you consume any of the following?
Coffee
Tea
Caffeinated Soda or Diet soda

How many cups a day?
Are you willing to give up on consuming caffeinated products or reduce the amount you intake?*
No
Yes
Do you have frequent sugar cravings?*
No
Yes

How often a week do you eat sugary food or beverages per week? *
Do you regularly eat of drink any of the following? (Check all that apply.)
Kelp
Seaweed
Sushi Rolls
Peanut Butter
Cow's milk
Yogurt
Cheese
Salty Food
Fast Food
Chinese Food
Soy
Processed Food
Deli meat
Peanuts
How much do you consume in a week?*
Do you take any Medications or Nutritional Supplements: (Vitamin, Protein Powders, Shakes, Smoothies, Homeopathic supplements?*
No
Yes

List all supplement or homeopathic medication.

How long have you been using it?

Reason for Use?

Nutrition & Diet:

Please specify in as much detail as possible all the meals and snacks you have had over the past three days.


*Day1 Breakfast: *

*Day1 Lunch: *

*Day1 Dinner: *

*Day1 Snack: *

*Day2 Breakfast: *

*Day2 Lunch: *

*Day2 Dinner: *

*Day2 Snack: *

*Day3 Breakfast: *

*Day3 Lunch: *

*Day3 Dinner: *

*Day3 Snack: *
Are you willing to change your diet?*
No
Yes

Click to customize text

V

*Important questions about your current daily skincare regimen:

Provide the name/brand of the each provide you're using.


*Facial Cleanser (Brand & Name)

*Toner (Brand & Name)

*Serum (Brand & Name)

*Moisturizer (Brand & Name)

*Eye Cream (Brand & Name)

*Sunscreen (Brand & Name)

*Masks (Brand & Name)

*Liquid Foundation (Brand & Name)

*Powder Foundation (Brand & Name)

*Concealer (Brand & Name)

*Blusher (Brand & Name)

*Bronzer (Brand & Name)

*Eye Makeup remover (Brand & Name)

*Shampoo (Brand & Name)

*Conditioner (Brand & Name)

*Leave-On hair products (Brand & Name)

*Toothpaste (Brand & Name)

*Lip Products (Brand & Name) *

Other topical facial products.

Daily Skincare Regimen:


MORNING REGIMEN: *

EVENING REGIMEN: *

WEEKLY/ MONTHLY REGIMEN ex. (masks, treatments)
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*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
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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