2 Week Follow-up Form

Please fill out the form below prior to making any changes to your provided homecare routine.  I will review your progress and contact you within 24 hours.    You may text any progress pictures to 316-734-6708

Please complete the form below

Date *
Date
Name *
Name
Phone
Phone
Address
Address
Are you still breaking out? *
Is your skin getting clearer?
Are you dry, peeling, flaky and/or red?