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Patient Intake Form - The Acne Program

Please answer all questions to the best of your ability. After submitting your intake form we will reach out for additional information including scheduling your consultation, The Acne Program fee ($100), and all necessary information needed. 


To make the process even easier you can pay The Acne Program consultation fee online. We will then start working on your customized program right away!

Buy The Acne Program

Are you currently using any of the following?*
Please mention when and for how long for applicable medications in the comment box below.
Have you ever had any allergic reaction to any skincare products in the past?
Check if you are allergic to:*
Do you consume alcohol?*
Do you smoke?*
Do you use fabric softener or fabric softener sheets in the dryer?*
Do you pick at your skin?*
Do you work around chemicals, tars, oils, inks?*
Are you currently under a lot of stress?*
Do you swim in chlorinated pools?*
Do you regularly ingest:
Check all that apply.
Are you on birth control pills or IUD?*
Are you pregnant or nursing?*
What are your skin care concerns?*
Check all that apply.
Medical History*
Please check all that apply.
Are you under a Dermatologist's Care?*
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