Acne Client Consent Acne Client Intake Consent Name First Last 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 PhoneEmail DOB*List topical and/or oral medications, How often do you apply or take them and for how long?*Medical History Check all that apply: Herpes Simplex Eczema Psoriasis Hepatitis Cancer Staph Infection/MRSA HIV/AIDS Thyroid Problems Hormone Problems Hysterectomy Ovary(ies) Removed Pacemaker Hemophilia Lupus Anemia High Blood Pressure Diabetes Metal Pins in Body Are you under a dermatologist's or other skin physician's care?* Yes No Have you ever had any reaction to any products or anything you have put on your face? If yes, what products?*Please check any of these you are allergic to: Sulfur Aspirin Laxtex List any other allergies you know of:*Do you smoke?* Yes No WOMEN: Do you use birth control pills, shots or use an IUD? If so, which do you use? What brand?*MEN: Do you have shaving irritation? What do you use for shaving?*DIET: Please list if you consume any of the following foods: Fast Food, Processed Food, Salty Snacks, Milk, Yogurt, Cheese, Whey or Soy Protein, Peanut Butter, Peanuts, Sushi, Kelp and Seaweed, Miso Soup, Soy Vitamins, Seafood? How often do you consume the listed foods?*HOME CARE REGIME: What are the names of the skin care products you are currently using? Cleanser, Toner, Serums, Moisturizers, Sun Screen, Mask, Foundation, Blush, Exfoliant (acids or scrubs) Acne Medications, Anything Else?*Other Treatments: What else have you done for your skin in the last 90 days? Glycolic/Lactic/Mandelic Peels, Other Chemical Peels if so what kind, Microdermabrasion, Laser Hair Removal, Laser Rejuvenation/Resurfacing, Skin Cancer Removal, Facial Waxing, Electrolysis, Other. When and Where?*How did you hear about us?*SignaturePhoneThis field is for validation purposes and should be left unchanged.