Simply Blush Skin Bar Virtual Consult
Name
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First Name
Last Name
Phone Number
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-
Area Code
Phone Number
Email
example@example.com
What’s your birthdate?
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How did you hear about Simply Blush?
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Medical History (dermatologist care, past surgeries, medications, accutane, adverse reactions, hormone changes, allergies, etc.)
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Have you been under another Esthetician or Injectors care? If yes, what are your previous treatments you have received?
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What are your skincare concerns?
What is your current skincare regimen at home?
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Select any that apply
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Sunburn or tanning bed within 30 days
Eczema, rosacea, or psoriasis
Botox or Filler within 2 weeks
Accutane within 6 months
Sensitive or Reactive skin
Chemical peels, lasers, microneedling, microdermabrasion, or microblading within 30 days
Pregnant, breastfeeding, or trying to get pregnant
None of the above
Are you looking for recommendations?
Homecare recommendations
Treatment recommendations
Both
Neither
Please upload photos of your skin.
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I have stated all conditions and circumstances regarding my health history.
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I understand that if I fail to follow pre and post care instructions it can affect the results of this treatment. I release Simply Blush Esthetics any liability associated with any injuries and future conditions resulting from the skincare treatment or products.
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