Virtual Consult Form

Virtual Consultation Form

The Simcoe Facialist
Name

First NameLast Name
Email
example@example.com
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Referred by

Other
Allergies? (Please list)
What are you hoping to get help with? Select all that apply.
What special areas of concern do you have with your skin (if more than one, please list from highest concern to least)
Which conditions would you like to improve

Other
Please list any skin conditions you have been diagnosed with in the past
How would you describe your skin?
Do you ever experience
Do you consider yourself to have sensitive skin?
If so, What sensitivities do you experience?

Other
Do you
Have you ever used
What medicated ointment/creams/lotions do you currently use
Do you wear sunscreen
Do you drink
Do you smoke Cigarettes
Have you had a reaction to
If so, please elaborate
How is your stress level
Do you sleep well
How many hours of sleep do you get in a day
Do you have any food intolerances or follow any special diet (fat free, low carb, sugar restricted, high protein? Please elaborate
Which of the following do you eat regularly
How many glasses of water do you consume daily
Are you pregnant or trying to get pregnant
Are you experiencing any hormonal imbalances
If so, please elaborate
What do you currently use in your skin routine (check all that apply)

Other
Do you use any skin devices at home and if so, what? (Ie. Dermaplane razor, microdermabrasion, LED, Pore Vaccuum, Dermaroller, Ice Roller, Jade Roller, Gua Sha Stone)
Give me a step by step guide of your current morning skin routine
Give me a step by step of your evening skin routine
What type of skincare routine do you prefer
This next section is for my acne prone clients. If you do not suffer from acne, please click the n/a option for each question
What age did your acne develop
Do you only breakout during your menstrual cycle?
What areas of the face do you get breakouts (Click all that apply)
Do you suffer from PIE (Red/Purple/Pink marks leftover from acne)
Any other skin questions, concerns or information I should know?
Are you comfortable with your photos being used in social media posts (ie. Before & Afters, testimonials)
Please upload photos of your skin. For a quality assessment, take close up photos in multiple angles and under natural lighting.

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I understand that skin results vary person to person (due to the genetic condition of the skin, consequences of not following the program etc) and that no specific results are guaranteed. I understand that the advice given to me by The Simcoe Facialist and all employees is not medical advice and to seek a physicians advice if need be. I accept any risks involved with using The Simcoe Facialist services or programs. I understand that Nicole Perdue (The Simcoe Facialist) is not liable for any harm, or injury that may result from her services or programs.
My signature below indicates that I acknowledge and agree to all the above statements in this consultation form.
Signature
Date of signature

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Virtual Consultation Form