working hours
& contact

Monday & Tuesday 9:00am – 5:00pm

Wednesday 9:00am – 7:00pm

Thursday & Friday 9:00am – 5:00pm

Saturday & Sunday Closed

1170 Dolphin st White Rock, BC, Canada V4B 4G8

Follow Us

Acne Consultation

    NEW CLIENT INTAKE FORM

    PRESCRIBED, OVER THE COUNTER AND RECREATIONAL DRUG / MEDICATIONS (PAST AND PRESENT USE):

    * Please mention when and for how long in each applicable field:

    SUPPLEMENTS


    CURRENT PRODUCTS - PLEASE WRITE PRODUCT NAME


    YesNo


    SulfurAspirinLatexNone


    YesNo

    LIFESTYLE CONSIDERATIONS


    YesNo


    YesNo


    YesNo


    YesNo


    Salty Foods

    Milk/Yogurt

    Cheese

    Processed Foods

    Whey/Soy Protein

    Peanut Butter/Peanuts


    YesNo


    YesNo


    YesNo


    BlackheadsDehydrated SkinDry/Flaky SkinOilyWhiteheadsDark SpotsSensitive SkinNormalPimples/PustulesAge SpotsRazor BumpsDryCystsBroken CapillariesShaving IrritationOily/DryOily SkinFine Lines/WrinklesAcne RosaceaSensitiveNone


    Glycolic Acid PeelsMicrodermabrasionChemical PeelsSkin Cancer RemovalPlastic SurgeryLaser Hair RemovalFacial WaxingElectrolysisOtherNone


    DiabetesHepatitisHemophiliaThyroid ProblemsHIV + or AIDSThrombosis/BloodClot/StrokeEczemaStaph Infection or MRSAMetal pins or brackets in bodyPsoriasisHormone ProblemsPacemakerPregnancyHerpes Simplex/Cold SoresHysterectomy/ovaries removedNursingHigh Blood PressurePCOSCancerAnemiaLupusNone


    YesNo

    YOUR PHOTOS*

    Please submit 3 photos of your skin: left side, right side and straight on.
    *Please take skin photos in natural light. (Facing a window is best.)
    **Please don't use direct sunlight or synthetic light (these create shadows).


    ( Ctrl + Click to select multiple photos )

     

    Call Us