CLIENT QUESTIONNAIRE

Name: Age: City:

_ (__)

Address: Work Phone: Cell

_l_/ State: Zip:

DOB:

(_)

Home Phone: EmailAddress:

Phone:(*-)

l. Prescribedu over-the-counter and recreational drugs/medications: (past and present)

Medication
Antibiotics Accutane BenzoylPeroxide Cleocin-T E-mycin-T
Rein A Cream or Gel

When

How Long

Medication
Testosterone Prooesterone Disufuram Cyclosporin
Dilantin

When

How Long

Thyroid Medication
Lithium

Tazarac
Differin

Quinine lsoniazid lmmuran

Danzol

Azelex Sulphur
Avita

Androstendione Cortisone Minosine Copazone

Gonadotroohin Steroids Marijuana Cocaine/Speed

ll. What else have you done for your skin:

Service
Glycolic Acid Peels lVicrodermabrasion Chemical Peels Dermabrasion Plastic $urgery Other:

When

Service
Skin Cancer Removal

When

FacialWaxing
Electrolysis Laser Hair Removal

lll. Products you are currently using: (please list product names)
Cleanser:
Toner:

Serums Moisturizers:
SPF: Mask:

Foundation: Blush: Exfoliant (ex: Glycolic)

:

Acne Medications: lV. Lifestyle considerations: 1. Have you ever had any reactions to any of the above products or anything you have ever put on your face? Yes No lf yes, which product{s): Describe your reaction :

tl

2. Please place a check if you are allergic 3. Do you Smoke? Yes

to: Sulphur

Asprin

Latex

No X

4. Do you use fabric softener or fabric softener sheets in the dryer? Yes
5. Do you pick at your skin? Yes

No

tr

il

No

[l

6. Do you work around chemicals, tars, oils or inks? Yes

No

7.

Are you currently under a lot of

stress? Yes

No

f
[I
No

8. Please place a check if you regularly eat or ingest: Fast Foods SushiI Salt Kelp Seaweed

9. WOMEN ONLY:Are you on birth control pills? Yes No n Are you taking Dep Provera shots? Yes No n Are you pregnant or nursing? Yes

tr

lf yes, which brand:

V.

Skin care concerns: (please check all that apply)

Dehydrated Dark n Age Broken Capillaries Fine LinesAlVrinkles X

Blackheads f Whiteheads tr Pimples/Pustules I n Cysts n Oily Skin

Skin f f Spots Spots I

Dry, Flaky Sensitive Razor Shaving lrritation Acne

Skin I Skin I Bumps n

n

Rosacea n

Vl. Describe your skin type:

Oily Normal Dry Oily/Dry Sensitive Diabetes Eczema Psoriasis Hepatitis Cancer

I I

tr

n n

Vll: Medical History: (please check allthat apply)

fl

Hemophilia n lf yes, name of doctor: Are you under a dermatologist's care? Yes I No I
Vlll: Miscellaneous:
1. Occupation:

n n n

HIV Positive/AIDS X Hormone Problems Hysterectomy i-l Ovary(ies) Removed

I f

Lupus
Thyroid Problems Herpes Simplex

Anemia

f ll High Blood Pressure I

2. How did you hear about us:

ACNE TREATMENT CONSENT FORM

An acne treatment may consist of surface cleansing, mild chemical peels or steam and exfoliation, application of antibacterial srums, correc ve serums and extrac ons. Treatments take approximately 20 to 45 minutes to complete and are designed to balance, hydrate, clear acne impactions and prepare the skin for the home care regimen. lmplements and equipment used in all this facility are disposable or properly sterilized according to the State Board of Cosmetology regulations. IMPORTANT: PTEASE READ CAREFUTLY and initial have not been exposed to excessive sun and my skin does not feel sensitive or irritated in any way. have not had any other chemical peel of any kind, within 14 days of this treatment. | have not had any facial waxing, within seven days of this treatment. have informed the clinic of all health problems of which I am aware. have informed the clinic of any use of oral or topical medications I may be using including Retinoids (Retin-A, Renova, Avita, Differin, Tazorac) or Accutane. understand that controlling acne/problem skin is best achieved through a series of recommended treatments and _l compliance to the home care product program recommended by a Face Reality certified esthetician. understand that I will probably not experience much visible peeling, flaking, discoloration or irritation following this _l

_l ---l ---_-t _l

procedure if I follow my homecare instructions carefuliy.

WARNINGS: PLEASE READ CAREFULTY and initial _Avoid direct sunlight or tanning booths for at least three days following a treatment _Use of sunblock protection of at least a SPF 15 is necessary following all treatmenls. _Do not pick your skin following a treatment
PRODUCT RETURN GUIDLINES: PLEASE READ CAREFULLY and

initial

treat problem skin conditions. Tingling painful. you product not be lf are experiencing stinging and irritation with any but should application sensations are normal with product, stop using the product and call your esthetician for further instruction. All returns must be made within 15 days of purchase for exchange or refund.
Face Reality Skin Care products are clinical-strength active formulas designed to RESCHEDULING GUIDELINES: PLEASE READ CAREFUTLY and initial A 24-hour rescheduling notice is required. We realize emergencies happen and

will be considered, but reserve the right

to charge a 550.00 fee for missed appointments without a 24-hour notice.

consent to photographs taken of my face to be used for

mon itoring

treatment progress.

I hereby agree to all of the above and agree to have this treatment be performed on me. I further agree to foliow all postffeatment care instructions as I am directed.

Name: Address: Signature of Client: Sienature of Esthetician: City:

Date: State:

Zip:

ACNE ANALYSIS AND CONSULTATION

Acne is definitely a four-letter word for people who suffer with lt is an inherited disorder of the pores pores that want to sludge up with dead skin cells much like a clogged drain in your sink. Normal pores shed about one layer of dead skin cells per day inside the pore. The acne-prone pore sheds up to five iayers of dead skin cells per day and the body just can't keep up. This forms blackheads or congestion under the skin; and if bacteria are present {which just loves to feed on the dead skin cells and oil}, you will get inflamed pimples or pustules. There are two types of acne (or sometimes a combination of the which type you are:

it.

two).

Your esthetician will determine

lnflamed Acne r:
a a a a I !

Noninflamed Acne n
a a a a

Redness/blotchiness Hot to the touch Pimples/pustules/whiteheads/blackheads Possibility of cysts

Excessive

Dull sluggish appearance

Bumps/blackheads
Some pimples/pustules
Excessive

oil

oil

Tissue congestion Skin is generally not sensitive or reactive

Skin is sensitive and reactive to products

Acne is a mysterious disorder, but one thing lS for sure - it can be controlled with the right combination of products used in the correct way. Just as in a clogged drain, the pore must be treated with products that unclog it and kill the acne bacteria. The Face Reality Skin Care system has what you need to do just this. The Face Reality Skin Care System will have your acne under control in about three to four months depending on your type of acne. lt combines the power of pharmaceutical-grade homecare products that are custornized for your type of acne and skin with a series of bi-monthly treatments that facilitate the clearing of your skin. You will be taught about other aggravating factors that rnake you break out - foods, medications, cosmetics, stress, and common ingredients in skin care formulations that might be clogging your pores{even professional and prescription productsl}. Your progress will be closely monitored by a Face Reality Certified Acne Specialist who will make sure you have the best regimen for your skin - making adjustments, if necessary, to get your skin healthy and clear in the fastest way possible.

ACNE TREATMENT AND APPOINTMENT GUIDE

the process of achieving clear skin you will want to come in every two weeks for treatments and for homecare adjustments. Treatments do the following:
As you go through

Reminders

1. 2. i. 4.

Exfoliate the skin so that home-core product con penetrate the Pore more eosilY. Hydrate the skin, if needed, so that the skin is receptive to your home-care regimen. The products also tend to dry out the skin somewhot as you ore getting used to
them. Extract existing scne impoctions. Kill ocne bacteria inside the pore.

You are required to give 24 hours notice if you need to reschedule your appointment or there will charge a $50 for a missed appointment with the exception of emergencies or if you are ill.
Please reschedule if you are ill.

Each treatment has a specific focus for what the skin needs at the time of treatment. Sometimes the skin will need more hydration, other times it will need more anti-bacterial action. Your esthetician will anolyze your skin at the beginning of every treatment fo sssess which treotment would serve You best,

Schedule your appointments at least 48 hours before any special events or projects where appearance is a factor. Treatments may cause some minor redness

and/or sensitivity. lf there is a problem with any of your products, cali anytime - someone will get back to you as soon as
possible. Bring in any new oral or topical medications prescribed by outside sources, for ony medical reason.

The other reason for seeing you every two weeks is to assess your horne care regimen. There will almost always be changes made to how you use your home care every two weeks to make sure you stay ahead of your skin's ability to adapt to products. Your clear skin expert will want to check and make sure that your home care is not too strong and irritating so you can achieve that balance between getting you clear as fast as possible without irritating and dehydrating your skin.

IMPORTANT! **lf, far some reoson, you con't mske it to yaur appointment every two weeks, you will need to call or email us for your next step in your bomecore regimen. Failing to do so will impede your progress and you won't get clear ss quickly. Treatments are per-formed every two weeks until your skin
clears.

Treatment Cost
Each acne A

treatment

is

S { -t

C".- (4"

.*

#yt,'Y {rr*

rl*t

g-,{j-,

first time discounted series is offered - !f yqu buy a series of three treatments, the total is 5 GL / @"LSf- *

,i,it trri

'-' lF f gf ''I'i'n* /t-.2 r.tvt, s.r1

j)yn

d' \),d

Lz*

LIFESTYLE CHOICES THAT AFFECT ACNE

Reduce Stress and Get Enough Sleep

Stress stimulates the adrenal gland and in the acne-prone individual,

the adrenal gland promotes

oil production which leads to clogged pores.

No Picking or Squeezing! Instead, rub ice on pustules and pimples for a couple of minutes, twice a day. Try to catch them when they are first forming and they most likely will go away. **IMPORTANT lf you pick, squeeze and breok the skin, thot scab will leave q red mark that will be there far months making your skin look WAY worse than if you left it olone.

Use Fragrance-Free Detergents fxamples of these are Cheer Free, All Free & Clear, Tide Free, Arm

& Hammer Free but there are

many on the market.

No Fabric Softener Do not use this in the washer and/or the dryer {no dryer sheets}. The waxy residue gets on your pillowcases, towels, wash cloths and sheets that have direct contact with the skin. lt will clog pores on acne-prone individuals. lf you are want somethinB to stop static cling in your dryer, you can get anti-static balls at Bed Bath and Beyond.
No Water Softeners There is some evidence that water softeners can lead to acne, especially those containing high amounts of potassium chloride. Sun Exposure and Acne. Although sun xposure causes desirable scaling and drying, it also damages the follicle, exacerbates hyperpigmentation, causes skin cancer and premature aging Warm climates with heat and humidity can exacerbate acne.

will be using a noncomedogenic sunscreen every day, not just to protect your skin from the sun, but to keep your skin hydrated during the day.
You

**IMPORTANT - Using it will keep your skin from getting dry from acne products!

r r

No "Lo" Dose Birth Control Pills Avoid low estrogen birth control pills. "Lo" dose pills are higher in androgen hormones that can make acne-prone skin worse.

Other Birth Control and Hormone Replaement Norplant, Provera, and Depo-Provera shots, Mirena and Nuvo Rings can cause breakouts. Also progesterone hormone replacement Premarin can be problematic, lf you have polycystic ovaries, they will cause hormonal changes and breakout.
For Swimmers Swimming pool disinfectants contain lodides and Chlorine, which can remain in the water, causing skin problems for frequent swimmers. Many swimmers find that the combination of hot and humid weather, the physical exercise of swimming and the chlorinated pools, can cause major acne flare-ups.

LIFESTYLE CHOICES THAT AFFECT ACNE

FOODS
This is a guideline only - you are not being asked to eliminate foods or food groups completely; these are only suggestions to cut back and moderate some food types. The "Try to Eliminate" group has been proven to be a problem for rnost acne sufferers. Sorne people have trigger

foodssuchascitrusbutthisisnotacrosstheboard. ltisbestifyoustartnoticinganycauseand effect with the foods you eat.

Try To Reduce lodized Salt Milk (including organic and especially nonfat)
Cheese

Acceptable Substitute
Sea Salt, Uniodized Salt, Celtic Salt

Peanut Butter Peanut Oil, Corn Oil, Canola Oil Whey or Soy Protein Shakes Kelp, Seaweed, Supplements Shellfish (for some people) Vitamins with iodides, iodine, kelp, potassium

Almond Milk, Coconut Milk, Rice Milk, Goats Milk Goat's Milk Cheese Almond Butter or other nut butters Olive Oil, Butter, Coconut Oil Pea Protein or Hemp Shakes

iodide

Dermavites or GNC Women's Ultra Mega Vitamins without iron

Also, try to cut back on caffeine and sugar products. Research has shown that high-glycemic diets can be a problem for the acne-prone,

SUPPLEMENTS
The following supplements have been found

to be useful in aiding your recovery from acne. Your esthetician may make recommendations based on the type of acne you have.

Zinc Monomethionine The most bioavailable form of zinc that acts directly as an anti-inflammatory. Many people with acne have low levels of zinc in their body; and supplementing with zinc has been shown to reduce severity of cysts and inflamed lesions. Omega 3 Fish Oils These are good fats that also act as an anti-inflammatory in the body. While recomrnended for all acne sufferers, they are particularly beneficial for women whose breakouts are linked to PMS. Omega oils also positively alter sebum production in the skin improving radiance and resilience of the skin.

Probiotics
Good bacteria that colonize the digestive tract and the skin. They can help people who have been on long-term antibiotics {both oral and topical). These good bacteria compete with the pathogenic bacteria and can help improve the incidence of breakouts. Good quality yogurts are a good choice or your esthetician can recommend a good brand available for purchase.

Pore Clogging Ingredients in Skin Care

Do not ever put anything on youf skin or your hair without checking the ingrdienB first, even if it says "won't clog pores" or "noncomedogenic" on the bottle. govemment agency oversees this so skincare companies can claim their products promote clear skin and have pore cloggers in their ingredient deck.

**Nctursl oils csn

be some of the atorst offenders like cocod butter dnd coconut oil which are found in mdny

"organi{

skin care lines.

Other oils such as jojoba, olive and lanolin are mildly comedogenic and can be a problem if formulated with other comedogenic ingredients. Some prescription products like the cream form of Retin A have pore cloggers. Many over-the-counter acne medications also have pore clogging ingredients.

"Oil-free' products can be comedogenic.

These are all ingredients that can agBravate acne. The higher the number assigned to it, the more propensity it has to clog your pores.

Makeup
The best makeup is one that does not contain comedotenic in8redients. Loose powder, mineral make-up tends

to

be the safest choice but still should be checked.

Bare Minerals Original Formula loose powder foundation is a safe choice; however the newer Bare Minerals Matte is NOT a safe choice

* it contains ActiveSoil

Complex that is causing breakouts for most users. Any pressed or liquid products also should be checked for pore-clogging ingredients. We do not recommend any of the pressed Bare Minerals blushes, bronzers or veils.

Ingredient
Acetylated Lanolin Acetylatd Lanolin Alcohol Algae Extract Algin Butyl Stearate Carrageenan Cetyl Acetate Cetearyl Alcohol + Ceteareth 20
Cocoa Bufrer

#
4 4
5 3 5

Ingredient
Laureth-23 Laureth-4 Lactic Acid Mink Oil Myristic Acid Myristyl Lactate

#
3 5

4
3 3

4
5

4 4

Myristyl Myristate
Octyl Palmitate Octyl Stearate

4
5
J

Coconut Butter Coconut Oil Colloidal Sulfur Coton Awws Oil Cotton Seed oil

4 4
3 3 3 3 5 3 3 3 3 3

Oleth-3
OIeyl Alcohol
PEG 16 Lanolin PEG 200 Dilaurate PEG 8 Stearate

4 4
3 3 3

D&CRed#17 D&CRed#2L

Monostearate PPG 2 Myristyl Propionate

PG

D&CRed#3 D&CRed#30 D&CRed#36

Decyl Oleate

Dioctyl Succinate Disodium Monooleamido PEG 2Disodium Monooleamido PEG 2- Sulfosuccinate Ethoxylated Lanolin Ethylhexyl Palmitate Glyceryl Stearate 5E 6lyceryl-3 Djisostearate Hexadecyl Alcohol Hydrogenated Vegetable Oil lsocetyl Alcohol lsocetyl Stearate lsodecyl Oleate lsopropyl lsostearate lsopropyl Linolate lsopropyl Myristate lsopropyl Palmitate lsostearyl lsostearate lsostearyl Neopentanoate

4
4
3 3 5 3

4
5

4
5 5 5

Polyglyceryl-3 Diisostearate Potassium Chloride Propylene Glycol Monostearate Red Algae Shark Liver Oil Sodium Chloride Sodium Laureth Sulfate Sodium Lauryl Sulfate Solulan 16 Sorbitan Oleate Soybean Oil Steareth L0 Stearic Acid Tea Stearyl Heptanoate Sulfaied Castor Oil Sulfated Jojoba Oil syearyl Heptanoate Wheat Germ Glyceride Wheat Germ Oil Xylene

4
5

4
5 3 5 3 5

4
3 3

4
3

4
3 3

4
3 5

4
3

PORE CLOGGING INGREDIENTS IN SKIN CARE PRODUCTS

Do not ever put anything on your skin without checking the ingredients first, even if the packaging says "won't clog pores" or "non-camedogenrb". Listed below are all the ingredients that can aggravate acne. The higher the number assigned to the ingredient, the more likely it is to clog your pores.

Ingredient
Acetylated Lanolin Acetvlated Lanolin Alcohol Alqae Extract Algin Butyl Stearate Carrageenan CetylAcetate CetearylAlcohol + Ceteareth 20 Cocoa Butter Coconut Butter Coconut Oil Colloidal Sulfur Cotton Awws Cotton Seed Oil D & C Red # 17

#
4

What the Ingredient is

Lanolins & Derivatives Lanolins & Derivatives Botanicals [/inerals Fattv Acids & Derivatives Botanicals Alcohols. Esters. Ethers & Suqars Alcohols, Esters, Ethers & Suqars Natural Oils Natural Oils Natural Oils Minerals Natural Oils Natural Oils Pigments Piqments Pigments Pigments Pigments Fatty Acids & Derivatives Fattv Acids & Derivatives Alcohols. Esters. Ethers & Suqars Lanolins & Derivatives Fatty Acids & Derivatives Alcohols, Esters, Ethers & Sugars Alcohols. Esters. Ethers & Suqars Alcohols, Esters. Ethers & Suqars Natural Oils Alcohols, Esters, Ethers & Suqars Alcohols, Esters, Ethers & Sugars Fatty Acids & Derivatives

4
4
a q

4
A L+

4 4 4
J

J J

D&CRed#21 D&CRed#3 D&CRed#30 D&CRed#36

Decvl Oleate Dioctyl Succinate Disodiurn Monooleamido PEG 2-Sulfosuccinate Ethoxylated Lanolin Ethylhexyl Palmitate Glvcervl Stearate SE G lyceryl-3- Di isostearate Hexadecyl Alcohol Hydrogenated Vegetable Oil lsocetylAlcohol lsocetyl Stearate lsodecvl Oleate

3
?
'J

4 ?

4 J
4
4

lsopropvl lsosterate lsopropyl Linolate lsopropyl Myristate lsopropyl Palmitate lsostearyl lsostearate lsostearyl Neopentanoate Laureth-23 Laureth-4 Lauric Acid Mink Oil Myristic Acid Myristyl Lactate Myristyl Myristate Octyl Palmitate Octyl Stearate Oleth-3 OleylAlcohol PEG 16 Lanolin PEG 200 Dilaurate PEG 8 Stearate PG Monostearate PPG 2 Myristyl Propionate Polyqlvceryl-3-Di isostearate Potassium Chloride Propylene Glycol Monostearate Red Algae Shark Liver Oil Sodium Choride Sodium Laureth Sulfate Sodium Lauryl Sulfate Solulan 16 Sorbitan Oleaie Soybean Oil Steareth 10 Stearic Acid Tea
D

5 5 5

Fatty Acids & Derivatives Fatty Acids & Derivatives Fatty Acids & Derivatives Fatty Acids & Derivaiives Fattv Acids & Derivatives Fatty Acids & Derivatives

4
4
?

4 3 4 4
5

4 4
3 3

3
4

4
4

5
J

3
4 2

4
3
4 e
J

Sulfated Castor Oil Sulfated Joioba Oil Svearyl Heptanoate Wheat Germ Glyceride Wheat Germ Oil Xylene

3
5

Alcohols, Esters, Ethers & Sugars Alcohols, Esters, Ethers & Sugars Fatty Acids & Derivatives Natural Oils Fattv Acids & Derivatives Fattv Acids & Derivatives Fatty Acids & Derivatives Miscellaneous Alcohols, Esters, Ethers & Sugars Alcohols, Esters, Ethers & Suqars Alcohols, Esters, Ethers & Sugars Lanolins & Derivatives Alcohols, Esters, Ethers & Sugars Alcohols, Esters, Ethers & Suqars Alcohols, Esters, Ethers & Sugars Fatty Acids & Derivatives Alcohols, Esters, Ethers & Sugars Minerals Alcohols, Esters, Ethers & Sugars Botanicals Oils Minerals Deterqents Detergents Lanolins & Derivatives Thickeners & Emulsifiers Natural Oils Alcohols, Esters, Ethers & Sugars Miscellaneous Fatty Acids & Derivatives Natural Oils Waxes Fatty Acids & Derivatives Alcohols. Esters. Ethers & Suqars Natural Oils Miscellaneous

DRUGS THAT eAN CAUSE ANDIOR AGGRAVATF ACNE

Certain drugs go beyond aggravating acne but actualiy cause acne in skins which otherrvise r.vould nct be vulnerabi*.

Recreational Dlltgs

. " r "

Marijuana
hormones.

aggravales acne ilecause it lowers testDsterone ieveis then raises tirese leveis praducing an irnbaiance in

Cocaine and Speed agBravate acfle Bromides - in cold and flu r*edications can aggraveie acne Steroids -Topical or oral cortiscosteroids {like Prednisone} are often used to treat asthrna and other chrenic lung diseases Like cor"tisoi, a natural steroid produced by the body during tinies of intense stress, corticosteroids can stimu!ate sebum production and lead to b!emishes. Dexamethasone, prednisoione, betamethasone, cortisone, hydrocortisone, and trlamcinolonel, and anabolic steroids {danocrine {Danazoi) and stanozoiol iStomba}j corticosieroicis [prednisone, methylprednisone can cause acne.

Prescription D!qg!

r r r r r . .' r . . .

Anticonvulsants - {tike Diiantin} are prescribed fcr the treatmenl of epiiepsy and other kinds of seizures. il,lost mdications in this familv iist acne as a .omrnon side effect. Lithium Carbonate --usecl to ireat Bipolar DisorCer Thyroid preparations - Some thyroid medications (such as Thiourea and Thioracil) are known to trigger acne. These preparations are used to stimulate the thyroid gland in patients with low thyroid function.
Quinine - prevents and/or treats malaria. INH {lsoniazid} - used to treat tuberculosis (TB). lmmuran - used to suppress the immune system in patients awaiting an organ transplant. Danazol - {Danocrine) Hormone management Hormonal medications - progesterone, androstendione, testosterone or contraceptive agents like Provera or DepoProvera) and older oral contraceptives-inewer birth controi pills such as Ortho Tri-Cyclen and Estrostep can actually improve acne) Gonadotrophin - may be prescribed in certain pituitary disorders can indirectly induce acne by stimulating testosterone production. Cyclosporin - this is for post-transplant patients who must take it to prevent organ rejection. Medications containing iodine or bromine - These medications are much less common today than in earlier years, but some are still in use. ln the United States today, it is probably more likely to see acne-like outbreaks resulting from heavy consumption of iodine-containing health foods such as kelp. The iodine-caused lesions can occur at any age, they occur rapidly after the consumptions of large amounts of iodine, they are likely to be widespread on the face and body, and inflammatory pustules are common. Disulfuranr (or Antabuse) - prescribed to help chronic alcoholic patints who want to remain sober. Phentermine - drug used for weight loss and appetite suppression ADD or ADHD drugs have been found to make acne worse.

r r r

CHEMTCAL TF,TAT CAN CAUSE AND/OR AGGRAVATE ACNE

Various chemicals are potent, and when they come into contact with the skin, aggravate acne.

. r r r

Coal tars - which a roofer comes into contact with Grease - an auto mechanic comes into contact with or from frying food that a cook would deal with Chlorinated industrial chemicals may induce the occupational skin disorder known as choracne. Dioxin - a chemlcal found in herbicides, and mav cause cancer and other harmful side effects.

ACNE MED (BENZOYL PEROXTDE) TNFORMATTON

Follow the Timetable

Benzoyl Peroxide can be extremely irritating and drying. During the initial weeks, you will experience some dryness, redness, itching, flaking, tightness or mild peeling. This is temporary and will subside as your skin adapts to the product. Try to put up with some peeling as it will eventually go away; but if you get "uncomfortably dry", then let us know.

Not on Eye or Lower Neck Do not use Acne Med on your neck or eye area as the tissue is too delicate and will irritate the skin

too much.
No Eye Cream Do not use eye cream or moisturizer around the eyes or neck because the acne Med will migrate through the cream and cause irritation and possible swelling.
Eye

lrritation

Allow your Acne Med to dry before going to bed. lf your eyelids get irritated, try changing your pillowcase more often. When you are wearing acne med all night, it will get on the pillowcase.
Smile Lines This area tends to be the most sensitive area on the face and will be the first place you see irritation and dryness. You can put a very thin layer of Vaseline on this area to occlude it for a few days and then resume product use there.

Not When Working Out Do not wear Acne Med when you expect to perspire, as in exercising or physical labor or getting hot in the sun. lf you are wearing it, wash it off or it will irritate your skin.

Will Bleach Fabric Acne Med will bleach fabric, so we suggest wearing a white shirt or T-shirt when using it. Also, use a white washcloth when removing from your skin, Use white pillowcases when you start wearing it overnight. Make sure and wash your hands with soap after using it to avoid bleaching towels.
Allergic Reaction
Allergies to benzoyl peroxide are rare but do occur occasionally. Dry skin does not constitute an allergic reaction; rather an allergy is characterized by itching, swelling or burning associated with a rash similar to a mild case of poison ivy dermatitis. lf an allergic reaction occurs, stop using Acne Med and contact us immediatelv. Use Religiously! lf you skip a day or two or only spot treat, it gives a chance for acne to form. You will never get clear if you skip your homecare.

The Do's and Dcn'ts of the Face Reality System

tDON'T forget your sunscreen in the mornir"igi

"/00 put on your sunscreen everyday, even if you aren't ieaving the house. Sunscreen protects yor.rr skin from pigmentation damage, and is ycur only moisturizeri /DO call u5, so we can work together to help with the dryness while keeping your skin clear! Acne Med PREVENTS new pimoles from forming, and new ones wili form if you skip even one night of using itl /DO call us, so we can work tsgether with tweaking your regimen, preventing possibie burning of the skin !
use white towels, piliowcases, sheets & wash your "DO with soap after appiying it prevent hands to accidental

r(DON'T stop using Acne Med if ycu get too dryi

rDCN'T use your products if they burn

or"

stingl

rcDON'T forget

thet Acne Med bleachesl

bleachingl

tDON'T use Acne Wash or Scrub to remove eye

makeup
!

r'DO use a non-comedcgenic eye makeup remover.

sDON'T moislurize or use any creams ON TOP of

Acne Medl

/DO call us so we can tweak your regimen to heip with dryness, or give you our water-based Hydrating f;mulsion to hydrate without weakening the Acne lv4ed.
u'D0 remember" that consistent usage of your products wiil KEEP you clear!
"'DO cail us to have us ship you products. You cafi get whatever you need in just a few days, forjust a few dollars in shipping costsl

xDON''l get comfortabie and stop using your products 0nce you are clear! xDCN'T run out of or sparingly use products!

xDON'T pickl

/DO icel Or, cail us for a free-of-chai"ge, quickie extraction at the clinic, between treatmentsl
!

Jc

DON'T overus product

/D0 call us if you need guidance on how to use your products and make them work more effectivelyl
i-Pod to listen to whiie yoll get treated, and DO breathe deeply and slowly to relax your bodyl

tDON'T be scared of extractionsl

/DO bring your

tDON'T use cotton balls or pads with your products, except with yor"rr toner!

/D0 appiy yolrr serums, Acne Med and Vitanrin A products with your bare hands to prevent wastel

Product Recsmmendations Price List

Product
CLEANSERS

Size

Price 5zq
524
528 528

Sitica Scrub

Sensitive Skin Cleansing Gel Acne Wash Acne Scrub

TONERS

8oz 8oz 8oz

8oz
8oz

Salicylic Antiseptic Toner Moisture Balance Toner

8oz
8oz

5zz s28
$22 526 510
S7o/51.7

Soothing Hydrating Toner

Glvcolic-Lactic Exfoliatins Toner ACNE MED PRODUCTS Acne Med 2.5% Acne Med 5% Acne Med 10% Acne Med 5%w/3%Sulfur Acne Med 7O%w/3%Sulfur
SERUMS

8oz

toz
1

oz/2 oz 1 oz/2 oz

s1o/s17 Srz

Loz

loz

itz

Salicvlic Serum 5% Glvcolic Serum 10% Glvcolic Serum 8% Mandelic Serum Lieht 8% Mandelic Serum 15% Mandelic Serum Lieht 15% Mandelic Serum Vitamin A Pro 1 Vitamin A Pro 2 Vitamin A Pro 3 Vitamin A Pro Liehtener
MOISTURIZERS

loz toz toz

Loz

Szq

522 524
s32 534 Sss 538
S32

Ioz
Loz
1oz Loz
Loz

Sra
s38
Ssg

Ioz
Laz
2oz 2oz 2oz 2az 2oz

Cranberry Cream Hvdratine Emulsion

MOISTURIZERS

5zz s22 Szr

5ze 524

Moisturizlns SPF 30
Broad Spectrum SPF 30 Dailv SPF 30 Lotion
HAIR CARE

Total Solution Hair Shampoo Total Solution Hair Conditioner

8oz
8oz

Srz
S12

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"*..-..*+.*.*

CLIENT AGREEMENT FORM

Remember:

r r .

We rnust strengthen your home care routine on a regular basis to keep your progress to clear skin moving forward. lf we don't change how you do your homecare often enough, your skin will adapt to the regimen and stop responding (in other words, you won't get clear). Every time we strengthen your home care/ we run the risk of drying and irritating your skin, so you will need to communicate that to us if that happens.

This is why close communicstion with us is key in gelting you clear in the tdstest possible way.
Please initial

the agreements below and sign at the bottom.

_L

ldeally, we want to see you every two weeks for an ane treatment while we are getting you clear (typically 3 months). lf, for some reason, if I cannot make it in every two weeks, I agree to call or email my skincare professional so we can strengthen your home care regimen.
I agree to contact My skincare professional immediately if I have adverse reactinns to products, I feel burning and/or stinging with any product, I get a rash and/or my skin becomes very dry and irritated before my next appointment.

_2. _

3. I will not use any other products that have not been approved by my skincare professional while I am on their regimen,
I wili not change the regimen given to me by my skincare professional without notifying or consulting with them first.

_4. _ _

5 | will not run out of product while working with my skincare professional. When you stop using products (or run out) acne will start forming inside the pores and you will see it about a month later.
6. I will not
have other skin care treatments while I am being treated by my skincare professional

_7"1

will inform my skincare professional of any medicationsldrugs that I start taking while on their regimen.

--- 9. I will inform my skincare professional if I elect to do any laser treatments _10. {For women) - | will inform my skincare professional if I get pregnant.

8, I will use my sunscreen every morning, regardless of whether or not I will be going outside. The sunscreen will help to keep your skin moisturized. Without it, your skin will get too dry.
or waxing for hair removal.

hereby agree t0 all of the above.

Date

How

tc use ysur pr*ducts

Mcrqing Rouline for Weeks'l +2

1,

Aene Wash

' A,cne Scrub Sensitive Skin Cleansing Cel Silica Scrub Usilig;riit|lervarrnr,v*ter,r,vashgeni1,vrviihr'rlr-rri!n{er|ips,a.,rlic1in.l
lce Face for Twri fiinutes

2.

(ln

inilanrt-d bre;lkouls" lce reclures irrflanrnralion;inrJ allc,,v: a<.nc rrt-tl l{) p:irelr.rfe hefter.

Paf dry iriler ir.irrg.

{{or m*:n: Sltaveii vtsu gef sll.*'rng irritalion,:iral'e in lhe clirecfjon ct{ !tair grc;rtrh, ,lr.'ori terlurnecj or "nrccjir;rlerj",rliavlne {re;}ffs anrj alierih-;te lclir.xs"j
Moisture Salance Soothing Hydrating ;\1:pl,l-rvitir;]i]()|10nr.tlund"Ir.lnershei;r|rrritJtireskirltli.anvresic]ui.t halanr e, lirerr:irv nr.iking it reaelv fr.rr rrrv;lr,irlic lrru*'l 1o Lrc a1:plii:ri rtexl.

3. Salicylic Clycr:lic

Toner

filycalic Salicylic Serum 4. Mandelic Vi{amin A Pro ,\pplv ,l lirin r:*;rt with vour harrr-is or iinqers lr.r enlirc i,lre inciticiirrg tire nE:rl: iand t:irrst ii iirokt,n oul).
,dpply eveirv other day for the {irst two rteeks.

lf there is stinging and hurning" wash it of{ a'ith w,attr and do not use it!

5. Cranherry

Cream

Aplrl-v hr:irlre sunscreen {r-rr rvilh sLrrts( ret:ltl lirr addi:ci nroi:fLrit'.

6" Daily SPF 30

Moigturizing SPf 3O

Broad Spectrurr 5FF

30

Sunscreen

Using.i-'nlal|.tllt,riltttt,'.lvcretl|itt]iar''e..iltrinerk,Rr:'applvirr;urivr,n.,lrl.ltliilrJirr:t-trulr
perspiring lc prevr.nl plernalure aeing. skin {ran{er, ;inrJ dark<.:ning r;{ hiperpignrenteci spots.

App{y every morning whether you are goit'tg ta be in the sun or not it afso helps to keep y*ur slrin nzoisturized wt'tich is very important.

HOW TO USE YOUH PRODUCTS

wewanr#H?"'""J:"[T,:i:,1;:'T#iJffi ;1l,H'TH:llf

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Weeks 3-4: You will now wear your serum every morning instead of every oiher morning (in the absence of irritation or severe dryness.)

Morninq Routine
Cleanser: lce face for 2 minutes Toner: Serum: Sunscreen:

Evening Routine
Cleanser; lce face for 2 minutes Toner: Antibacterial: (Acne Med for spot treatment):

Weeks 5-6: You will now wear your serum twice daily.

Morning Routine
Cleanser: lce face for 2 minutes Toner: Serum: Acne Med for spot treatment: Sunscreen:

Evening Routine
Cleanser: lce face for 2 minutes Toner: Serum: Antibacterial: (Acne Med for spot treatment):

Weeks 7-8: We may ask you to wear your Acne Med in the rnorning at this point.

Morning Routine
Cleanser: lce face for 2 minutes Toner: Serum: **(Acne Med): Sunscreen:

Evening Routine
Cleanser: lce face for 2 minutes Toner: Serum: Antibacterial: (Acne Med for spot treatment):

**Allow the Acne Med to absorb for 15-30 minutes before applying sunscreen.

Morning Routine
Cleanser: lce face for 2 minutes Toner: Serum: {Acne Med): Sunscreen:

Evening Routine
Cleanser: lce face for 2 minutes Toner: Serum: Antibacterial: (Acne Med for spot treatment):

Weeks'|-1-12

Morning Routine
Cleanser: lce face for 2 minutes Toner: Serurn: (Acne Med): Sunscreen:

Evening Routine
Cleanser: lce face for 2 minutes Toner: Serum: Antibacterial: (Acne Med for spot treatment)

Birth control for acne simnlified

Birth control pills are widely used today and prescribed often as a means to control acne. Most pills can have the potential to cause acne and weight gain in those susceptible. Typically the pills are divided up as estrogen or

progestin dominant and have varying degrees of androgenic (testosterone like) effects. As a general rule of thumb, pills with the potential for higher androgenic symptoms should be avoided for people prone to acne because they promote breakouts. As an acne sufferer it is important to speak with your doctor about a selecting a pill that is higher in estrogen and lower in androgen potncy.
Th most commonly prescribed pills in this category are:

Diane 35{Dianette)
Yasmin

Denrulan(Zovia)

Ortho tri cyclen

Nevicon modicon

Ortho evra Mircette

Desogen(Apri)

It is best to avoid the following pills that are high in androgen activity and low in estrogen. which are some of the following:
Loestrin Estrotrep Fe
Levlen Alesse

Ovral Norestrin

Nuvo ring
Mirena ring Depoprovera shot

Only you and your doctor can determine what pill is right for you. The above is just a basic Auideline that should be used to initiate a conversation between you and your physician. If you are considering taking birth control pills, it is

important to know that they are associated with a high risk of blood clots, weight garn, nausea, mood changes, depression and breasi tenderness. Serious side effects include strokes, digestive issues and embolism.
Finaily, it is entirely possible to treat acne without going on the pill at all. If you have no underlying health issues ihat require you to be on bifth control and are considering taking birth control pills only to control your acne, please feel free to talk with one of the estheticians to get some additional perspective on how we can help you with the use of

topical products and treatments.

lmportant Information about Zinc

These supplements can upset your stomach. To prevent nausea, always take OptiZinc with food. Zinc is an essential trace element for humans and there is evidence that it is similar to antibiotics in improving the condition of inflamed acne. The effective dosage is not clear. However, most studies indicate

50-100mg {The OptiZinc tablet that we sell are 30MG). We advise you to not take any more than 100mg because excessive zinc may lead to deficiencies in other vitamins and minerals. One of the reasons that we like OptiZinc is that it contains copper and copper is one of the minerals that can be depleted by taking zinc supplements. We are also recommending that you discontinue taking the zinc once you are completely

clear. We are not

recommending this as a preventative. lf you would like more information to help you make decisions about the benefits, proper dosage and best formulation of zinc supplements, we highly recommend doing your own resear.h on the internet.

Instructions for takins figh oil capsules for vour acne

Research and anecdotal evidence suggests that many of us who suffer from chronic inflammatory acne rnay benefit frcm taking relatively higher doses (1000-1700mg) of purified omega- 3 oils present rnostly in wild

ocean fish such as salmon, mackerel, cod and herring. Omega-3 oils are anti-inflammatory and the body utilizes them in many ways. Of particular relevance to acne sufferers. they may help regulate hormones and in addition help to shorten the intensity of your breakout. Please note: that although there is no known toxicity associated with using fish oils over long term, you should check with your physician particularly if you have a chronic underlying illness or are pregna nt.

We have chosen a high quality fish oil supplement to help with your acne. Our fish oil capsules are of therapeutic quality and are enteric coated to help assimilate the omega-3's in the most efficient way possible. In addition they are formulated not to have a fishy after taste and are guaranteed burp free.
Pf

ease take 1 capsule/2 capsules with the lightest meal of the day.

P--'F**'