What skin concern are you experiencing?
Select that apply
Clogged pores
Acne lesions
Skin hyper-pigmentation
Fine line/wrinkles
Uneven skin texture
Looking to prevent sun damage/sign of aging
Other
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Please describe your skin concerns in detail
Include any associated symptoms and if you have ever been previously evaluated or given a diagnosis by a physician
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What skin concern are you experiencing?
Select that apply
Face
Neck
Chest/Back
Extremities
Other
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How long have you been experiencing symptoms?
Select that apply
1-3 months
3-6 months
6-12 months
More than 12 months
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Have you experienced any of the following symptoms along with your current skin complaints?
Select that apply
Skin lesion that rapidly changing in size, shape, or color
Skin lesion that is bleeding or painful
Skin lesion that has become ulcerated/an open sore
Skin lesion that is red/scaly/itchy
Skin blisters
Other new/concerning symptom
None of the above
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Have you used any products/treatments in the past for your primary skin complaint?
Yes
or
No
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Does any of the following apply to you?
Select that apply
Normal (feels balanced and not easily irritated)
Dry (feels tight and rough)
Oily (feels shiny)
Combination (oily in some areas and dry in others)
Sensitive (easily irritated by skin products)
I’m not sure
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Do you have any underlying chronic skin conditions/issues
Select that apply
History of Melanoma or other skin cancer
Rosacea
Eczema
Sun sensitivity
Perioral Dermatitis
Other
I have no other skin conditions
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Do you have any other chronic medical conditions?
Yes
or
No
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Are you currently pregnant, breastfeeding, or planning to become pregnant in the next 3-6 months?
Yes
or
No
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Do you currently have or have you had any history of mental health conditions?
Yes
or
No
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How long ago was your most recent check up with a physician?
Within past year
Within 2 years
Within 3-5 years
Over 5 years
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Do you have any more questions or anything else you would like your doctor to know?
This includes weight, blood pressure, and heart rate
Yes
or
No
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Please acknowledge that you understand and agree to the following
I have filled out a medical intake form that will be used by a board certified physician that is licensed in my state to make a medical treatment plan for me.
I understand all the questions that have been asked of me.
The information that I have provided is accurate and complete.
I am the patient who is consenting to be evaluated for treatment via telehealth.
I don’t remember
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