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Name *

First Name

Last Name

Phone *

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How severe is your acne? *

Mild (Less than 10 active acne lesions at a time)

Moderate (10 to 20 active acne lesions at a time)

Severe (More than 20 active acne lesions at a time)

How long have you been struggling with acne? *

Less than 1 year

A few years

Ever since I can remember

Lifestyle adjustments are a very important component of the Acne Program, and may include changes to your daily habits, diet, beauty products, and other areas of your life. Are you willing to make these changes in order to achieve and maintain clear skin long-term? *

Yes

No

Maybe

The Acne Program is a financial investment, but clients also need to invest their time, energy, and a positive mindset into the program for best results. Are you willing to invest in the program financially, mentally, and emotionally? *

Yes

No

Maybe

Most acne clients achieve clear skin in 4 to 6 months, but this timeline may vary. Are you willing to be patient, understand that your acne may take several months to clear, and also understand that maintaining clear skin is a long-term process? *

Yes

No

Maybe

What appointment times work best for your work/life schedule? (Select multiple if your schedule is flexible) *

10:00-11:00 Morning

12:00-1:00 Early Afternoon

3:00-4:00 Later Afternoon (WAITLIST)

5:00-6:00 Evening (WAITLIST)