New Client Intake Form Name* First Last Email* We will be following up with you on how to begin via email so please use the address you check most frequently! We will never sell your email or spam.What is the best number to reach you?*How did you hear about us?*GoogleInstagramFacebookYoutubeA Friend/ Family memberModern Luxury Wedding MagazineDecatur LivingYoutubeIf it was a friend or family member, who can we thank for referring you?Please list any any all medications you are taking , prescribed or recreational:*Please be sure to let us know the details of your medications (i.e. %, mg, dosage, and how you use them & when)Please choose any/ all health conditions you have been diagnosed with:* Lupus AIDS/HIV Blood Clots/Stroke Hepatitis Herpes Simplex/Cold Sores Hormone Problems PCOS Staph Infection/MRSA Thyroid Disease None Are you taking any vitamins or supplements? Please list all.*Have you ever had an allergic reaction to a product? (Please describe)What are your skin care goals?Upload clear, well-lit, in focus photos of your acne affected area(s) here.Face (left side) (if affected)Face (right side) (if affected)Face (center or front) (if affected)Chest and/or arms (if affected) Drop files here or Back (if affected) Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.