Acne Bootcamp Application

Your Contact Info

First Name

Last Name

Address

Street Address

City

State

Zip Code

Phone/Mobile

Date of Birth

Who were you referred by?

Your Skin History

Are you currently under the care of a dermatologist?

Yes

How long have you been seeing a dermatologist?

What is your current regimen and for how long?

What are your current results?

When was your last visit to the dermatologist?

What were your end results?

Do you feel as though you have tried everything with the dermatologist and it is not working for you?

Yes

What else have you tried in the past for your acne?

How tired are you of having acne on a scale of 1-5?

1=😏 It bothers me but I deal with it and feel like makeup is a good fix.

2=😔 I feel embarrassed and makeup is not enough for me. I am looking for an easy solution and quick fix.

3=☹️ I have tried everything I know to do as well as different over-the-counter products.

4=😫I have tried professional help from a dermatologist and have tried getting facials by a licensed practitioner and it is not working

5=😭Can’t take it another day. Causing problems in my social and emotional life.

Your Diet

Are you currently taking birth control?

Yes

When did you stop taking birth control? (Skip this if you have never taken it)

List any foods you are allergic to or sensitive to?

What is your diet like?

Your Stress

Do you like to challenge yourself?

Yes

How do you feel when you overcome big obstacles?

How would you rate your stress levels? (0 being stress-free and 10 being the most stressful)

What do you do to eliminate stress?

Upload your photos

Please follow the examples given below for both side views and a front-facing view of your face.

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Your Contact Info

Your Skin History

Your Diet

Your Stress

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