BEFORE YOU FILL OUT THIS FORM PLEASE READ THIS.

A FEE OF USD $50.00 APPLIES TO DELIVER YOUR CUSTOMIZED ACNE PROGRAM.

The terms:

  1.  The $50 consultation fee is to be paid.
  2. Please fill out the form and upload your photos.
  3. A clinically trained medical aesthetician will comprehensively evaluate your history.
  4. If additional information is required, we will request it from you via email.
  5. We will inform you via email when we have formulated an appropriate treatment program for you. This may also include prescription cream recommendations.
  6. We will direct you to a physician / skin care specialist for product purchase (USA & Caribbean only).
  7. Your fee includes a link to a free book download on naturally maintaining good skin, including natural skincare recipes.
  8. NOTE: Once we have delivered your recommendations, the fee is non-refundable.
  9. FORMS SUBMITTED WITHOUT PAYMENT WILL NOT BE ACKNOWLEDGED.

Your Name (required)

Your Email (required)

Your Age (required)

Are you under the care of a Dermatologist?
 Yes No

What acne medications were you prescribed?

Did your prescribed acne medications work and how long were they effective for? Please describe

Do you have an allergy / particular sensitivity to any of your acne medications? Please describe.

Do you have scars and skin depressions from your acne?
 Yes No

Do you have dark marks and discolorations from your acne?
 Yes No

Please describe other medications, vitamins, and herbal supplements you use.

Please select which are a regular part your diet.
 Dairy Sushi Iodized salt Vitamin E Supplements Omega Oil Supplements Fish Oil Supplements Multivitamins

Please select all your life-style choices, habits and situation.
 Alcohol more than 2 days a week Cigarettes Marijuana Sleep less than 6 hours a night Night-shift job Job exposure to chemicals and oils High stress levels Regular sun exposure Body building Frequent cell phone use with facial contact Pomade (hair grease) use Heavy makeup use Picking of acne Allergies

List any underlying medical conditions you have.

List all products you use now for your acne.

List all products you think are working for you.

Do you need products shipped to you?
 Yes No

Which country do you live in? (Required)?

UPLOAD PHOTOS (REQUIRED)
To allow us to do a comprehensive acne analysis, we need good quality photos done under very good lighting. Please take the following photos WITHOUT FLASH:

• A full frontal face
• 2 side profile shots - right and left (to highlight the temples and cheek bones)
• 2 side shots at a 45º angle (to highlight the cheeks, and partial front of the face)

Full frontal

Right profile shot

Left profile shot

Right 45º angle

Left 45º angle

Submit other questions and queries here:

Once you have submitted your information, Click the “Buy Now’ button below to process your consultation.

NOTE: FORMS SUBMITTED WITHOUT PAYMENT WILL NOT BE ACKNOWLEDGED.