acne bootcamp submission

Name

First Name

Last Name

are you pregnant or trying to become pregnant?

what would you describe your skin type as?

within the last year, have you been under a dermatologist care?

if yes, please specify

have you had health problems, past or present?

if yes, please specify

do you have any allergies to products, medications, food, etc?

if yes, please specify

have you ever experienced burning, itching or stinging sensations when using certain products?

if yes, please specify

do you have any skin conditions pertaining to your face or body?

(ex: eczema......etc)

if yes, please specify

have you used Accutane, Retin A, Retinol or any other prescription skin care in the last 14 days?

if yes, please specify

have you had chemical peels, Microdermabrasion or any other resurfacing treatments in the last 30 days?

if yes, please specify

is there any additional information about your current or previous health history that your skin care professional should be aware of?