Virtual Consult Form

  • Virtual Consultation Form

    The Simcoe Facialist

  • Please be honest when filling out this form. If you do not fully disclose information asked, any services I may provide based on the information you give me could result in an unfavourable outcome, which I will not be liable for. The information you provide is in confidence and will not be shared with outside parties.

  • Format: (000) 000-0000.
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  • Referred by
  • Which conditions would you like to improve
  • Have you ever seen an esthetician 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?
  • How would you rate your skin?
  • Do you
  • Have you ever had
  • Does your skin heal fast
  • Do you get sores/blisters (Herpes Zoster/Shingles)
  • Have you ever used
  • Any personal or family history of skin cancer?
  • How would you describe your overall health
  • Have your ever had any of the following, past or present
  • If you get a pimple, do you pop it?
  • Do you wear sunscreen
  • Do you drink
  • Do you smoke Cigarettes
  • Have you had a reaction to
  • How is your stress level
  • Do you sleep well
  • How many hours of sleep do you get in a day
  • Do you exercise regularly
  • Which of the following do you eat regularly
  • Are you any of the following:
  • In our treatment program, it may be necessary to recommend alterations to or additions in your home care regimen, would that be okay with you?

  • For Women

  • Are you pregnant or trying to get pregnant
  • Are you experiencing any hormonal imbalances

  • For men

  • Do you experience skin breakouts or ingrown hair when shaving?
  • What is your facial hair like?
  • What do you currently use in your skin routine (check all that apply)
  • What is most important to you in skincare? (Pick one)
  • What else is important to you in skincare (check all that apply)
  • What type of skincare routine do you prefer
  • Do you find it difficult to stick with a routine everyday?

  • 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

  • Do any of your immediate family members suffer from acne?
  • 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)
  • Are you comfortable with your photos being used in social media posts (ie. Before & Afters, testimonials)
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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 will not receive a refund if I do not see the results I desire. 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. 

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