Virtual Skin Consult

Virtual Skin Consult

Please complete and return within 24 hrs prior to your virtual consultation. Thank you!
Date*

MonthDayYear
Name*

First NameLast Name
Date of Birth*
Address*

Street Address

Street Address Line 2

CityProvince

Postal Code
Cell Number

Area CodePhone Number
Alternate Home Number

Area CodePhone Number
E-mail*
example@example.com
Website / Online SearchYelpFacebookInstagramReferralOther
If Referral, please list name
If Other, please let me know
Your Skin
What is your goal for your skin ? *
What is the main reason for a consult?
Are you currently using of have you used Accutane in the last six months?Are you pregnant or nursing / lactating?Do you have a history of cold sores (Herpetic breakout?)Do you have any allergies?Did you have any cancerous lesions removed in the area you wish to treat?Are you currently undergoing CHEMOTHERAPY?Are you on any oral CHEMOTHERAPY drugs?Do you have any autoimmune illnesses?Please elaborate on any of the above, using the "Other" section belowNone of these apply to meOther
Are you currently using any topical prescription drugs on the area of concern?Are you currently using prescription or non-prescription Retinols, or Retin-A?Are you currently using prescription or non-prescription Acne medication, i.e., Accutane or Tazorac?Are you currently using prescription or non-prescription AHA/BHA?Do you have any medically diagnosed skin issues? If yes, please list in "other" section.Have you ever had an adverse reaction from skincare products? If yes, please list in "other" section.Please elaborate on any of the above, using the "Other" section belowNone of these apply to meOther
Please provide a clear photo of the FRONT of your face using the front camera of phone or tablet.
Please provide a clear photo of the RIGHT SIDE of your face.
Please provide a clear photo of the LEFT SIDE of your face.
SensitiveDryNormalCombination / Oily T-ZoneOilyThick SkinFine SkinOther
AcneAcne ScarringFew Pimples / BlemishesHormonal AcneAdult AcneClogged Pores / Bumps Under SkinTextural ChangesEnlarged PoresUneven Skin ToneHyperpigmentationMelasmaSun DamageBroken CapillariesSensitivityIrritationRedness-ProneRosaceaWrinkles / Fine LinesAgingOily / Excessive OilDehydratedOther
In your own words, please describe your skin.
Describe your skin as it once was to how it is now.
YesNo
If yes, how long ago and what kind?
Was it a professional facial or at home treatment?
Cleanser / Face WashBar SoapFace Scrub / ExfoliantsEnzyme PeelTonerTarget serums for anti-agingTarget serums for acneTarget serums for rosaceaTarget serums for oily skinMoisturizerSunscreenEye Product(s)Lip Product(s)Mask treatments for home useOther
What do you enjoy using the most?
What drives your decision when choosing products; texture, scent, clean science/natural, price point, elegant feel?
What has your experience been like in the past year with your current choice in skincare and are these products taking care of your immediate skin concern(s)? *
Have you seen results?
Yes, currently usingYes, but not on a regular basisNoNot sure? Please list what you are currently using in "Other" section belowOther
What is your ethnic background?
Does your skin change seasonally?
What happens to your skin?
A lotA lot in the past, not so much nowMinimalAverageI'm outdoors a lotI wear sunscreen every dayI only wear sunscreen when I'm by the waterOther
IPL Photo Facial for PigmentationRaised Bump / Blemish RemovalIPL Photo Facial for broken CapillariesIPL Photo Facial for Collagen BoostIPL Photo Facial for Skin TighteningIPL Photo Facial for AcneBotox / FillersHome Care Skincare RegimenI'm not sure and would like your adviceOther
YesNo
Conclusion And Consent
Thank you for this great information provided today! It will be part of your client profile and kept strictly confidential. With your consent, I will send you an invitation to my AlumierMD web portal, where you will have access to your customized skincare regimen. Under your own "Prescription Pad" I will select products with specific ingredients which will address the concern(s) you have listed above and / or will be discussed during your personal consultation.*

I consent to sharing this information with CONFIDENT IMAGE CHEZ FRANCE and ALUMIERMD Labs and give permission to communicate with me via email.
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation when using medical grade ingredients which are of higher concentration than over the counter / drug store cosmetics and I release this Skincare Professional from liability and assume full responsibility thereof.*

Yes
Signature*

Clear
CONFIDENT IMAGE CHEZ FRANCE

36 Hiscott St. Unit 100B Ground Level, St. Catharines, ON L2R 1C8

info@confidentimage.ca

www.confidentimagechezfrance.com

(905) 931-0686
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Virtual Skin Consult

Your Skin

Conclusion And Consent