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Step 1 of 3
Patient Name
Parent or guardian name if applicable
Have you had a serious reaction to any acne treatments before?
Do you have any allergies?
Are you pregnant, planning pregnancy, or is there any possibility that you could be pregnant? (copy)
Are you breast feeding?
Have you started puberty?
Are you willing to use contraception for at least 1 month before starting treatment, during treatment, and for at least 1 month after stopping treatment?
Do you have perioral dermatitis (redness and soreness around your mouth) or rosacea?
Are you currently using any other treatments for acne?
Have you recently received an acne treatment containing antibiotics?
If you have used acne treatments before, did you experience any side effects or skin irritation?