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Clear Path Acne Clinic/ABQ Acne Clinic

Acne Consult Form

*We respectfully ask that you do not bring children under the age of 10 to accompany you to your appointment unless the appointment is for them. Please help us maintain a quiet and peaceful environment for all of our clients.

TODAY'S DATE: April 16, 2024

Please select who will be participating...
AdultMinor
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First Client's Name

First Name*

Last Name*
First Client's Date of Birth*
First Client's Information

Work Phone:

Home Phone:

Cell Phone:

Ethnicity
First Client's Signature*
Client's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Background Information

Prescribed, Over the Counter and Recreational Drug/Medications (past and present use): Please check all that apply.

Antibiotics
Accutane
Benzoyl Peroxide
Clindamycin Topical
Adapalene
Retin A Cream or Gel
Tazorac
Differin
Azelex
Sulfur
Clindamycin Oral
Androstendione
Cortisone
Minocycline
Copaxone
Testosterone
Progesterone
Disufuram
Cyclosporin
Dilantin
Lithium
Thyroid Medication
Quinine
Isoniazid
Immuran
Danzol
Gonadotrophin
Steroids
Recreational Drugs
Antidepressants
Other

If Other, please list:

If you selected any of the choices above, please describe When and for How Long
Do you or have you had any of the following medical conditions:
Epilepsy
Seizures
Heart Disease
Pace Maker

Products now using - please write product name


Cleanser:

Toner:

Serums:

Moisturizers:

SPF:

Mask:

Foundation:

Blush:

Exfoliant (ex. Glycolic):

Acne Medications:
Have you ever had any allergic reactions to any of the above products or anything you have ever put on your face?*

If yes, what product:

Describe:
Check if you are allergic to
Sulfur
Aspirin
Latex
Do you smoke?*
Have you been diagnosed with rosacea?*

If so, by whom?

Please list makeup you are currently using (foundation, powder, blush, bronzer, primers, concealers).

Please list hair products you are currently using (Shampoo, Conditioner, Hairspray, etc)

Lifestyle Considerations


At what age did your acne start?

At what age did your parents/family member STOP breaking out?
Are you prone to Keloids?*
No
Yes
I'm not sure
Do you have a water softener?*
No
Yes
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 or inks?*
Are you currently under a lot of stress?*
Do you regularly eat or ingest:
Beef
Dairy
Kelp/Seaweed/Sushi
Nuts
Resaurant Foods/Fast Foods
Salt
Soy
Sugar

Are you currently taking any multi-vitamins or supplements? If so, which ones?

Are you currently consuming any type of protein or protein shake? If so, which ones?

Do you have any picking tools? (Describe)

Do you play a musical instrument or sport?

Women only: 


Are you using a birth control method? If so, which one?

Please provide name of birth control method:

Are you pregnant or nursing?

If pregnant are you using prenatal vitamins?
Women- Facial Hair Removal Methods:
Razors
Waxing
Electric Shaver
Threading

What are your skin care concerns:

Blackheads
Whiteheads
Pimples/Pustules
Cysts
Oily Skin
Dehdyrated Skin
Dark Spots
Age Spots
Broken Capillaries
Fine Lines/Wrinkles
Dry,Flaky Skin
Sensitive Skin
Razor Bumps
Shaving Irritation
Acne Rosacea
Oily
Normal
Dry
Oily/Dry
Sensitive

What else have you done for your skin:

Glycolic Acid Peels
Microdermabrasion
Chemical Peels
Skin Cancer Removal
Plastic Surgery
Laser Hair Removal
Facial Waxing
Electrolysis
Other

If Other, please list:

Medical History: check any condition you may have had in the past two years

Diabetes
Hepatitis
Hemophilia
Thyroid Problems
HIV + or AIDS
Thrombosis/Blood Clot/Stroke
Eczema
Staph Infection or MRSA
Metal pins or brackets in body
Psoriasis
Hormone Problems
Pacemaker
Pregnancy
Herpes Simplex/Cold Sores
Hysterectomy/ovaries removed
Nursing
High Blood Pressure
PCOS
Cancer
Anemia
Lupus

Are you under a Dermatologist's Care? If so, name of Dr.

What kind of work do you do?
How did you hear about us? *
Google
Facebook
Instagram
City Lifestyle
Referral

If referred, by whom?

What results would you like to obtain with your skin?
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Work Phone:

Home Phone:

Cell Phone:

Ethnicity
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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