Online Skin Consultation & Assessment
By The Esthetic Queen
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you wish to get your results via e-mail or via text message?
*
Via Email
Via Text
Have you ever had professional help with skincare regimens / treatments prior?
*
Yes
No
If yes, what have you tried prior?
Did you like it, did you feel a change within your skin, when was your last treatment?
Are you looking for procedures or product recommendations?
*
Procedures
Products
Both
What steps do you currently have incorporated into your skincare regimen?
*
Cleanse
Second Cleanse
Scrub
Toner
Serum
Eye Cream
Mask
Daily Moisturizer
Night Moisturizer
SPF
Spot Treatment
Acne Medication
Hydrators
Lip Hydrators
If you checked any boxes above, please list here the brands/names of each product.
Realistically, how many steps do you think you’re willing to commit to for your morning and night routines?
*
Less than 3
Less than 5
I will do whatever I need
Which of these best represents your skin?
*
Dry
Oily
Combination
Sensitive
Mature
Acne Prone
Rosacea
Eczema
Hyperpigmentation
Dark Circles
Psoriasis
Dullness
Large Pores
Melisma
Other
If you do struggle with acne, Is it year round or only occasionally?
Year Round
Occasionally
I don't struggle with acne
How often do you exfoliate?
*
If on any medications or prescriptions please list them below.
What are your overall skin goals, skin concerns, questions, etc.
*
How do you feel about your skin today?
*
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
If you are looking to receive treatment(s) what days and time work best for you and your schedule?
Regarding your skincare products, if you would wish to stay below a specific budget you can write that here, as I always try to work within those requests.
How did you hear about me?
*
Please upload updated pictures of your skin - in natural lighting to make it easy to see to properly address your concerns.
*
Browse Files
Drag and drop files here
Choose a file
Left Side / Forward Facing / Right Side.
Cancel
of
Auto Invoice Option (optional) Click “YES” if you’d like me to send you an invoice via email for the recommended and customized skincare, so you can see total cost breakdown + pay directly via invoice to avoid website confusion/fees.
*
YES
NO
Save
Submit
Should be Empty: