Clear Skin Starts Here! ***Please be sure to check your junk/spam mail for our response! 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 * Our success with teens has been minimal. If you are a parent filling out this form for your teen, please ensure that your teen is genuinely interested and willing to commit to their skincare journey. Consistency and effort on their part are essential for achieving results. We’ve found that the best outcomes happen when teens are actively involved and take responsibility for their routine—our role is to guide and support, not to micromanage the process. This requires their active participation and dedication. 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 Are you currently taking prescription medications for acne or using Accutane or Tretinoin? * 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 Are you ready to fully commit to using your skincare regimen twice a day, every day? Consistency is key to achieving the results you’re looking for—no skipping or excuses! * 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) * Is there anything you would like to share with me? Are you looking to work with Skin Junkie virtually or in-person? Teens are eligible for virtual consultations only, while adults have the option of either virtual or in-person appointments. In-person sessions include professional chemical peel treatments that can speed up the clearing process for faster results. Please note that 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, so it’s essential that we work directly with them to achieve the best outcomes. * Thank you!Please be sure to check your junk/spam folder regularly for a response. We will respond within 24-48 hours.
