Virtual Facial Form

Virtual Facial Form

Checking for Contraindications
Name
DOB

MonthDayYear
Occupation
What type of skin do you have?

NormalOilyDrySensitiveReactive
What areas of concern do you have regarding your skin?

Uneven Skin ToneBlackheads/WhiteheadsAgingRednessBreakouts/AcneBroken CapillariesOther
Have you been under the care of a doctor within the past year?

YesNo
If yes, please explain
Do you take any medications? If so, please list
Have you ever had an allergic reaction to any of the following?

FacialAHAsCosmeticsMedicineFoodAnimalsSunscreenDrugsIodinePollenFragranceShellfishLatexOther
Are you currently using any beauty devices in your daily regimen?

Clarisonic BrushMy Skin BuddyNuFaceLightSlimOther
Is SPF part of your daily routine?

YesNo
What is your current level of stress?

NormalLowHigh
What is your current weather climate?

HumidDryDepends on the day
Is there anything I should know about you, your health, or history that has not been discussed? Please explain
If you could wave a magic wand, how would your skin look and feel after our virtual facial? Please explain
Anything else you want to share? I love learning about my clients as it helps me provide superior customer service.
Do you agree to the terms and conditions of the facial kit?

YesNo
Signature

Clear
Printed Name
Date

MonthDayYear
Mailing Info (for facial kit)
Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Email
example@example.com
Phone Number

Area CodePhone Number
Please include any additional important mailing info below to ensure product arrives on time, such as gate code, apartment number, or delivery instructions.
Should be Empty:

Virtual Facial Form

Mailing Info (for facial kit)