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2 Week Follow-Up Form

Today's Date*
MM slash DD slash YYYY
Name*
First Last
Email Address*
Home / Cell Phone*
Address*
Street Address Address Line 2 City State ZIP Code
Your progress
Are you still breaking out?*
- Yes
- No
Is your skin getting clearer?*
- Yes
- No
- I am already clear
If already clear skip to the product order section of the form.
How long have you been on your routine?*
How many days per week have you skipped your serum or acne med?*
Write out your morning and evening routines step by step.*
What products, if any, are burning, stinging or itching?*
Are you dry, peeling, flaky and/or red?*
- Yes
- No
If yes please describe:*
Additional comments or questions:
Upload Photos
Take 3 photos of your skin and upload them below.

NOTE: Before uploading, please rename photos with last name, first name and angle. Ex: smith-mary-leftside.jpg
- One from straight on
- One from your left side
- One from your right side< /br> - Do not use a flash
Photos (max size 128MB each)*
Drop files here or
Accepted file types: jpg, png, Max. file size: 256 MB, Max. files: 5.
Order Products
Would you like to order products?*
- Yes
- No
Which products?
Please list the products you would like to order here

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Get in touch

599 Watervliet Shaker Rd
Latham, NY 12110
518-378-4763
clearsolutionsacne@gmail.com

Located inside Myo Massage.

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