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Long Distance Check In

Please submit this form every two weeks. We will email you any changes you need to make to your current regimen.

Your Personal Information:

*Name:

*City

*State (or Province) *Country

*E-mail:

 

Routine for:* (date mm/dd/yyyy)

 

MORNING ROUTINE

(F=Face; B=Body; C=Chest)

 

Check if Yes

 

Any tingling stinging, burning, redness?

Cleanser

 

 

 

Acne Wash

F B C

 

F B C

Acne Scrub

F B C

 

F B C

Silica Scrub

F B C

 

F B C

Sensitive Skin Cl. Gel

F B C

 

F B C

 

 

 

 

Toner

Check if Yes

Every other day?

Any tingling stinging, burning, redness?

Salicylic Toner

F B C

 

F B C

Glycolic Toner

F B C

 

F B C

Mandelic 3%

F B C

F B C

F B C

Mandelic 9%

F B C

F B C

F B C

Herbal Toner

F B C

 

F B C

Prime pH Toner

F B C

 

F B C

 

Serum

Every other day?

Every day?

Morning and Mid-day?

Any tingling stinging, burning, redness?

Salicylic 7%

F B C

F B C

F B C

F B C

Glycolic 5%

F B C

F B C

F B C

F B C

Glycolic 10%

F B C

F B C

F B C

F B C

Polygel 8%

F B C

F B C

F B C

F B C

Polygel 15%

F B C

F B C

F B C

F B C

Derm A Gel

F B C

F B C

F B C

F B C

Exfol A

F B C

F B C

F B C

F B C

Exfol A Forte

F B C

F B C

F B C

F B C

Bleach Forte

F B C

F B C

F B C

F B C

Superlightener

F B C

F B C

F B C

F B C

Mandelic 8%

F B C

F B C

F B C

F B C

Mandelic 15%

F B C

F B C

F B C

F B C

Lactobase A

F B C

F B C

F B C

F B C

 

 

 

 

 

Hydrator

Every other day?

Every day?

Morning and Mid-day?

Any tingling stinging, burning, redness?

Hydrating Emulsion

F B C

F B C

F B C

F B C

 

 

 

 

 

Acne Med
a.m. routine

Every other day?

Every day?

Morning and Mid-day?

Any tingling stinging, burning, redness?

2.5%

F B C

F B C

F B C

F B C

5%

F B C

F B C

F B C

F B C

10%

F B C

F B C

F B C

F B C

5% with sulfur

F B C

F B C

F B C

F B C

10% with sulfur

F B C

F B C

F B C

F B C

A02 Cream

F B C

F B C

F B C

F B C

 

Moisturizer/
SPF

Every
day?

Oil Free SPF 30

F B C

Micro TZ

F B C

SPF for Acne Prone Skin.

F B C

Solaris

F B C

 

 

EVENING ROUTINE

(F=Face; B=Body; C=Chest)

 

Check if Yes

 

Any tingling stinging, burning, redness?

Cleanser

 

 

 

Acne Wash

F B C

 

F B C

Acne Scrub

F B C

 

F B C

Silica Scrub

F B C

 

F B C

Sensitive Skin Cl. Gel

F B C

 

F B C

 

 

 

 

Toner

Check if Yes

Every other day?

Any tingling stinging, burning, redness?

Salicylic Toner

F B C

 

F B C

Glycolic Toner

F B C

 

F B C

Mandelic 3%

F B C

F B C

F B C

Mandelic 9%

F B C

F B C

F B C

Herbal Toner

F B C

 

F B C

Prime pH Toner

F B C

 

F B C

 

Serum

Every other night?

Every night?

Any tingling stinging, burning, redness?

Salicylic 7%

F B C

F B C

F B C

Glycolic 5%

F B C

F B C

F B C

Glycolic 10%

F B C

F B C

F B C

Polygel 8%

F B C

F B C

F B C

Polygel 15%

F B C

F B C

F B C

Derm A Gel

F B C

F B C

F B C

Exfol A

F B C

F B C

F B C

Exfol A Forte

F B C

F B C

F B C

Bleach Forte

F B C

F B C

F B C

Superlightener

F B C

F B C

F B C

Mandelic 8%

F B C

F B C

F B C

Mandelic 15%

F B C

F B C

F B C

Lactobase A

F B C

F B C

F B C

 

 

 

 

Hydrator

Every other night?

Every night?

Any tingling stinging, burning, redness?

Hydrating Emulsion

F B C

F B C

F B C

 

 

 

 

Acne Med

Worn for how many minutes?

Wearing all night every evening? (Check for YES)

Wearing all night every other evening? (Check for YES)

2.5%

F B C

F B C

F B C

5%

F B C

F B C

F B C

10%

F B C

F B C

F B C

5% with sulfur

F B C

F B C

F B C

10% with sulfur

F B C

F B C

F B C

A02 Cream

F B C

F B C

F B C

 

Moisturizer

Wearing all night every evening? (Check for YES)

Cranberry Cream

F B C

Ultra Hyaluronic

F B C

 

 


Are you currently experiencing any of the following:

Skin Condition

If so, where?

On a scale of 1 – 10, ten being very irritating, what # would you give this condition?

Dry

Peeling

Flaking

Irritation

Stinging

Itchiness

Redness

Dark spots

OTHER THINGS WE NEED TO KNOW

 

YES

NO

Are you getting new breakouts?

Is your skin getting clearer?

For darker skin tones only: Is your skin getting dark patches that weren’t there before?

If so, where?

Have you skipped any days of doing your home care routine? (please be honest here – it helps us to help you!!)

If yes, how many days in a week have you skipped?

Please write out your current routine step by step:


How long have you been on your current routine?

 

Reminders:
1. Don’t wait for us to contact you – if your skin is getting too dry and/or irritated contact us immediately. Not doing so could impede your progress

2. Send us photos no less than every month – we really need to see your skin!!

3. We need to know where you are with your homecare every two weeks. Ultimately, we want to strengthen your routine every two weeks so your skin will clear more quickly.

4. We will need to know all of the above information about your routine.

Additional Comments or Questions:
 
 

 

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