ACNE CONSULTATION FORM
In order for us to create the most effective and safe treatment plan that is customized just for you, we must collect certain personal and medical information. PURE Skincare & Acne Spa will never share or disclose any information that you share with us.
Email address *
Name *
First and Last
Your answer
Address *
Your answer
Phone number *
Your answer
Who were you referred by?
(google, yelp, family, friend, etc)
Your answer
Which of the following best describes your skin type?
Please list any known allergies:
Your answer
Are you allergic to any of these things?
Please inform us of any Prescribed, Over the Counter and Recreational Drug/Medications (past and present use):
Which of these best describes your current home skin care routine?
Describe the products you use morning and night:
Cleanser, Toner, Serums, Moisturizers, SPF, Mask, Foundation, Blush, Exfoliant (ex. Glycolic), Acne Medications, etc. (Please write product name)
Your answer
Have you used any Alpha Hydroxy Acid (AHA) or Beta Hydroxy Acids (BHA) in the past 48-72 hours?
Such as glycolic, lactic, salicylic, mandelic, etc
Are you exposed to the sun on a daily basis or do you use a tanning bed?
Have you tanned in the last 24 hours?
Have you ever had a reaction to a skin care product, treatment or waxing? (Please Explain)
Your answer
Medical History:
Check any condition you currently have or may have had in the past two years.
Are you under a Dermatologist's care?
At what age did your acne start?
Your answer
Do you use fabric softener or fabric softener sheets in your laundry?
Do you pick at your skin?
Do you work around chemicals, oils, tars or inks?
Do you smoke?
Are you currently under a lot of stress?
Do you regularly eat or ingest:
Women Only: Are you on birth control? If yes, please list name or method of birth control.
(Pill, IUD, Shot, Arm Implant, etc)
Your answer
Women Only: Are you pregnant, nursing or trying to become pregnant?
Men Only: Do you get irritated from shaving?
Men Only: What do you use to shave?
Your answer
Friendly Reminders Before your 1st Appointment: New clients must fill out all consultation forms prior to their first appointment. New clients are advised to stop using current acne medications and/or Retinol creams, prescription and over the counter, at least one week prior to your first appointment. New clients MUST REFRAIN from receiving chemical peels, laser treatments and facial waxing AT LEAST 2 weeks prior to first treatment. Plan on spending $100-150 for your first set of products (most of the products will last around 3 months). We require you to use our products exclusively in order to participate in the acne program. This helps us monitor your skin properly and will guarantee that you aren’t using anything with pore-cloggers that could slow down your skin's progress. Please reschedule your appointment in a timely manner if you have a sunburn or non-acne related skin issues (example: cold sores, skin cancer or mole removal, etc.)
By selecting "Yes", I agree and understand the information provided. We will be unable to provide a treatment if consent terms are not accepted.
ACNE TREATMENT CONSENT: An acne treatment may consist of surface cleansing, mild chemical peels or enzyme exfoliation, application of antibacterial serums, corrective serums and extractions. Treatments take approximately 30 to 50 minutes to complete and are designed to balance, hydrate, clear acne impactions and prepare the skin for the home care regimen. Implements and equipment used in all this facility are disposable or properly sterilized according to the State Board of Cosmetology regulations. I hereby consent to and authorize Holly Roth, Licensed Esthetician, to perform the requested services. I have voluntarily elected to undergo this treatment/procedure after the nature and purpose of this treatment has been explained to me, along with the risks and hazards involved. Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications. I also recognize there are no guaranteed results and that independent results are dependent upon age, skin condition, and lifestyle and that there is the possibility I may require further treatments of the treated areas to obtain the expected results at an additional cost. I understand how important it is to follow all instructions given to me for post-treatment care. In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult Holly at Pure Skincare & Acne Spa immediately. I have also, to the best of my knowledge, given an accurate account of my medical history, including all known allergies or prescription drugs or products I am currently ingesting or using topically. I have read and fully understand this agreement and all information detailed above. I understand the procedure and accept the risks. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I do not hold Holly Roth or Pure Skincare & Acne Spa responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed at my appointment/s. *
By selecting "Yes", I agree and understand the information provided. We will be unable to provide a treatment if consent terms are not accepted.
CANCELLATION POLICY: If you need to reschedule or cancel an appointment, I require a minimum of 24-hours notice. Please call or text (989) 307-9369. If there is no answer, please leave your information on the voice mail and/or text your cancellation as proof of your cancellation contact. I do understand that things happen beyond our control and will do my best to accommodate your needs. My online booking system sends out 2 reminders, 48 and 24 hours in advance. Please understand that it is your responsibility to remember your appointment dates and times to avoid late arrivals, missed appointments and any cancellation fees. Clients that "no show" appointments or give less than 24 hours notice may be invoiced a cancellation fee equal to 50% of their scheduled service, which would need to be paid before booking future appointments, and repeat offenders may be required to pay in advance for future services. Because Pure Skincare & Acne Spa is by appointment only, your appointment time is reserved exclusively for you and I request that you please respect the cancellation policy. LATE ARRIVALS: If you arrive late, your session may be shortened in order to accommodate others whose appointments follow yours. Depending upon how late you arrive, I will then determine if there is enough time remaining to start a treatment. Regardless of the length of the treatment actually given, you will be responsible for the full session. Out of respect and consideration to me and other customers, please plan accordingly. Thank you for understanding!! *
By selecting "Yes", I agree and understand the information provided. We will be unable to provide a treatment if cancellation terms are not accepted.
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