Virtual Consultation Form

Virtual Consultation Form
This consultation card is used to evaluate your individual skin care needs. We will maintain the confidentiality of this information, and will disclose this information only to 1)Our Staff & 2) Our product supplier and manufacturer (if the result of a reaction). We will not provide the information to anyone else, except as required by law, and we will not sell this information to anyone.
Name*

First NameLast Name
Phone Number*
Email*
example@example.com
Date of Birth*
MM/DD/YYYY
Your Health
1. Within the last year, have you been under a dermatologist’s or other physician’s care?
If yes, please specify
2. Have you had any health problems in the past or present?
If yes, please specify
3. List any medications, supplements, vitamins, diuretics, Isotretinoin, etc. that you take regularly:
4. Do you smoke?
5. Do you exercise regularly?
6. Do you follow a strict diet?
9. Your level of stress (1-5 being low, 5-10 being high)
10. Do you have any allergies? Latex, nickel, etc.
If yes, please specify
11. Have you ever had an allergic reaction to aspirin?
12. Do you sunbathe or use tanning beds?
13. Do you drink more than 4 caffeinated beverages daily?
Your Skin
15. What are your specific concerns or challenges with your skin?
16. Have you had a chemical peel, microdermabrasion, laser or light therapy, and injectable or other cosmetic procedure in the last month?
17. Have you waxed in the last 3 days?
18. Do you use Retin-A, Renova, Adapalene, or any other prescription skin products in the last three months?
19. Have you taken isotretinoin (Accutane) within the last 6-12 months?
20. Are you currently using any products that contain the following ingredients? Select all that apply.

Glycolic AcidLactic AcidExfoliating ScrubVitamin AOther Acid ingredient
21. Do you ever experience these conditions?
22. Do you use SPF on your skin?
23. Do you burn easily in moderate sunlight?
24. Have you had any direct sun exposure within the last 48 hours?
25. Do you have a tendency to redness?
26. Do you suffer from sinus problems?
27. Are you prone to cold sores or fever blisters?
28. Are you currently experiencing a breakout?
29. Do you ever experience burning, itching, or stinging sensations on your skin?
If yes, please specify
30. What skin care products are you currently using? Select all that apply.

SoapCleanserTonerMoisturizerExfoliatorSerumEye Product
31. Are you taking oral contraception?
32. Are you pregnant or trying?
33. Are you lactating?
34. Are you currently menstruating or due to?
I confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. I also acknowledge that in order to keep record of my treatment progress photo records are necessary. My esthetician has authorization to take these photos for progress tracking. These photos may be used in social media, website, or print and my identity can be protected upon request. By signing this I acknowledge and agree to all terms.*

I agree

Payment*

USDConsultation Fee

Payment Methods

Credit Card

Apple Pay

Google Pay

Cash App Pay

Add any additional notes here:
Date*

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Date
Signature*

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Virtual Consultation Form

Your Health

Your Skin

Payment Methods