Name
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First Name
Last Name
Email (Please provide an email that you check regularly, this is how I'll follow up with your Application)
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Phone
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(###)
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Birth Date
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We work independently with individuals who are 18 or older and able to take full responsibility for their skincare journey. If youβre under 18, weβre unable to offer services at this time. All forms must be filled out by the person receiving care β not by a parent or guardian.
Skincare success depends on personal commitment, consistency, and open communication. If youβre ready to take that step for yourself, weβre here to guide and support you.
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How long have you been struggling with acne?
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What have you done about your breakouts so far?
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Are you currently under the care of a dermatologist?
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Are you currently taking prescription medications for acne or using Accutane or Tretinoin?
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Please list everything you are currently using on your skin.
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What is the severity of your acne?
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The goal of this treatment plan is to help you achieve clear skin without needing prescription meds long-term. Thatβs why we recommend working with your doctor to start weaning off of them before beginning treatment with us. Just a heads-upβsometimes this can cause a short-term increase in breakouts as your hormones start to rebalance. Totally normal, and weβll guide you through it every step of the way. Do you understand?
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Are you willing to make the necessary lifestyle changes & adjustments to your diet, daily habits, and cosmetics in order to get clear? These are necessary and person dependent in order to achieve clear skin.
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Are you ready to fully commit to using your skincare regimen twice a day, every day? Consistency is key to achieving the results youβre looking forβno skipping or excuses!
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On a scale of 1 - 10, how likely are you to commit to following our guidance? (twice daily use of homecare/follow up appointments/lifestyle & diet adjustments)
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Current Skincare
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Please list everything you are currently using on your skin. Brand + product
Checkbox
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This is an all-inclusive skin plan, meaning your regimen, treatments, and guidance all work together as one complete system. Itβs designed to remove guesswork, streamline your routine, and get you results without conflicting advice or products.
If you feel the need to mix in outside products or follow tips from other sources, this may not be the right fit. The best results come when we follow one plan, start to finish, without detours. Are you all in?
Are you looking to work with Skin Junkie virtually or in-person? Teens are eligible for virtual consultations only if they are 18 or older and have a personal email address. In-person appointments are reserved for adults 21 and over. In-person sessions include professional chemical peel treatments, which can speed up the clearing process for faster results. Please note: If you are an adult managing the clearing process for your teen, results are likely to be minimal. This process requires personal independence and commitment from the teen themselves β direct communication is essential to achieving the best outcome. Please answer virtual or in-person below.
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Is there anything you would like to share with me?
