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Let’s fix your acne
This takes less than 5 minutes

How this works

• Complete this secure form with your information.

• A qualified medical professional will review your answers in detail.

• You will receive a comprehensive review, including product and lifestyle recommendations, delivered confidentially to your email address.

What is your first name?

What is your last name?

How old are you?

How would you describe your acne?

Mild (a few pimples)

Moderate (frequent breakouts)

Severe (painful or cystic acne)

Which specific areas of your body are affected by acne?

Face

Back

Chest

Other

How long have you been dealing with acne?

Less than 3 months

3–12 months

1–3 years

More than 3 years

Have you used any topical medications in the past? Please describe.

Yes

Do you currently follow a skincare routine? If yes, please describe your skincare routine and list the products you use.

Yes

Are you currently on any medical treatment for acne? If yes, please specify.

Yes

Are you currently taking any vitamins or supplements? If yes, please list them.

Yes

Which of the following do you consume frequently in your diet?
(Select all that apply)

Which of the following do you consume frequently in your diet? (Select all that apply)

Sugary drinks (soda, packaged juices)

Refined carbohydrates (white bread, pastries, sweets)

Dairy products (milk, cheese, shakes)

Protein supplements (whey protein)

Fast food / highly processed foods

None of the above

Please upload clear, well-lit images of only the affected skin areas. Ensure the images are focused and show details of the skin condition.

What bothers you the most about your acne?

You’ll receive:

1. A personalized acne plan

2. Based on your skin and photos

Delivered within 24 hours or less

Where should we send your acne plan?

(Email address)

Let’s fix your acneThis takes less than 5 minutes