The Clear Skin Method Application Name * First Name Last Name Email (Please provide an email that you check regularly, this is how I'll follow up with your Application) * Phone * (###) ### #### Birth Date * Applicant must be 18 years or older. Unfortunately, our success with teens has been minimal. This program requires 100% commitment and self responsibility. MM DD YYYY How long have you been struggling with acne? * What have you done about your breakouts so far? * Are you currently under the care of a dermatologist? * Yes No What is the severity of your acne? * Mild - less than 10 acne lesions Moderate - 10 - 20 acne lesions Severe - 20+ acne lesions 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. * Yes No Our acne clients are usually able to obtain clear skin in 3 - 4 months, but some cases take longer and vary depending on your health and overall commitment to the program. Are you willing to be patient and do you understand that maintaining clear skin is a long term process? * Yes No Business hours are Tuesday - Friday 10 - 5. (Last appointment beginning at 4:30) Does your schedule allow for in person appointments during these hours? * Yes No On a scale of 1 - 10, how likely are you to commit to the program? (2x daily usage of homecare/follow up appointments/lifestyle & diet adjustments) * This is a program, not a one time appointment. There are multiple follow up/treatments involved. Therefore, scheduling all appointments at once is required. Please review the FAQ's page if you need to read more about how the program works. * Please do not continue with this form if you can not commit to the program. Do you understand? Is there anything you would like to share with me? Thank you!
