Reset Intake Forms Name * First Name Last Name DOB * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Checkbox * Check Any Of The Following Drugs/Medications You've Used Antibiotics Accutane Benzoyl Peroxide Retin A Differin Testosterone Progesterone Thyroid Medication Steroids Anything Else? List The Products You're Currently Using, Including Makeup * EG: Cleansers, Toners, Exfoliants, SPF, Topical Medications Are You Allergic to Any of the Following? * Sulfur Aspirin Latex None Any Other Allergies? Do You Smoke? * Yes No Do You Pick at Your Skin? * Yes No Sometimes Are You Currently Under a lot of Stress? * Do You Work Around Chemicals, Tars, Oils or Inks? * Yes No Do You Regularly Eat Any of the Following? Check all that Apply * Kelp Seaweed Sushi Salt Fast Foods Dairy Soy Protein Shakes or Bars Peanuts/ Peanut Butter List Any Medications or Supplements You're Currenlty Taking * Are You on Birth Control? What Method? * Are You Pregnant or Nursing? * Yes No What are Your Skin Care Concerns? Check any that Apply * Blackheads Whiteheads Pimples/Pustules Cysts Oily Skin Dehydrated Skin Dark Spots Age Spots Broken Capillaries Fine Lines/ Wrinkles Dry, Flaky Skin Sensititve Skin Razor Bumps Shaving Irritation Acne Rosacea What Else Have You done for Your Skin? * EG: Peels, Microdermabraion, Skin Cancer Removal Check any Medical Condition You May Have Has in the Past 2 Years * Diabetes Eczema Psoriasis Hepatitis Cancer Lupus Celiac Disease HIV/AIDS Hormone Problems Historectomy/Ovaries Removed Hemophilia Thyroid Problems Herpes Simplex/Cold Sores Anemia High Blood Pressure Epilepsy/Seizures None Are You Under a Dermatologists Care? * Yes No What Kind of Work do You do? How Did You Hear About Us? * Yelp Google Instagram Passing By Friend What Are Your Goals for Your Skin? * Anything Else You'd Like Me to Know? Consent & Agreement Program Commitment * I understand the Virtual ace Reset is an 8-week guided program that requires my active participation. I agree to follow the skincare regimen provided to me to the best of my ability. I agree to submit progress photos every two weeks as requested. Products and Instructions * I understand my products will be shipped to me after my intake form and consultation are completed. I will use my products only as directed and wont make changes to the regimen without first discussing with Amy Earnest. If I incorporate LED into my regimen I will follow all safety guidelines provided. I understand clinical-strength products may cause mild tingling or dryness but should not be painful. If irritation occurs, I will discontinue use and contact my esthetician. I undertsand my home-care products are customized for me and should not be shared. Results and Limitations * I understand that individual results may vary and cannot be guaranteed. I acknowledge that external factors (diet, stress, hormones, lifestyle) may affect my skin's progress. I release Amy Earnest Skincare from liability related to factors outside of her control. Behavior Guidelines * I understand that skin picking, squeezing, or manipulating breakouts may cause irritation, scarring, or delay results. I agree to avoid picking during the program and will reach out if I’m struggling with this habit. I understand that consistent use of my prescribed routine and timely check-ins are essential to progress. Your program includes scheduled FaceTime check-ins. These are a required part of your progress and must be completed on time. If you miss or reschedule more than once without 24 hours’ notice, that check-in will be considered forfeited. Missed or forfeited check-ins cannot be rescheduled or refunded. Consistent communication is part of the program’s success — repeated missed appointments may limit your progress. Photograph Consent * I consent to photographs of my progress for treatment monitoring. I consent to anonymous use of my photographs for promotional purposes, with no compensation expected. Agreement * I have read and understand all of the above. Digital Signature * (Type your full name to sign below) Date of Consent * MM DD YYYY Thank you for submitting your forms!
