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About Acne & Skin Care
Virtual Clear Skin Support
New Client Intake Form
We will be following up with you on how to begin via email so please use the address you check most frequently! We will never sell your email or spam.
What is the best number to reach you?
How did you hear about us?
A Friend/ Family member
Modern Luxury Wedding Magazine
If it was a friend or family member, who can we thank for referring you?
Please list any any all medications you are taking , prescribed or recreational:
Please be sure to let us know the details of your medications (i.e. %, mg, dosage, and how you use them & when)
Please choose any/ all health conditions you have been diagnosed with:
Herpes Simplex/Cold Sores
Nut or Tree Nut Allergy
Are you taking any vitamins or supplements? Please list all.
Have you ever had an allergic reaction to a product? (Please describe)
What are your skin care goals?
Upload clear, well-lit, in focus photos of your acne affected area(s) here.
Face (left side) (if affected)
Face (right side) (if affected)
Face (center or front) (if affected)
Chest and/or arms (if affected)
Back (if affected)
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