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.
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Date of Birth

MonthDayYear
Date
What pronoun do you follow (ie. He, She, Them)
Dermatologist (if not applicable, physicians name)
Current Occupation
Ethnicity
Referred by

FriendSocial MediaGoogle SearchOther
Allergies? (Please list)
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

AcneAcne ScarringAge SpotsEnlarged PoresFine Lines and WrinklesHyperpigmentationBroken CapillariesStretch MarksFacial ScarsDehydration and/or DrynessExcess OilCompromised/Damaged Skin BarrierRosaceaMaintenanceOther
Have you ever seen an esthetician in the past?

Yes, RegularlyYes, Once/OccassionallyNo
If so, What was your experience like? If not, any particular reason?
Please list any skin conditions you have been diagnosed with in the past
How would you describe your skin?

OilyDryComboNormalNot sure
Do you ever experience

FlakinessRednessTightnessExcessive oily shine during the day
Do you consider yourself to have sensitive skin?

NoYes
If so, What sensitivities do you experience?

BreakoutsRedness/FlushingRashBurningHyperpigmentationFlakingRedness/Flushing only after being touched that lasts less than 10 minutesOther
How would you rate your skin?

Always burns, never tansAlways burns, tans slightlyBurns moderately, tans graduallyRarely burns, deep tanNever burns- Deeply pigmented
If you are exposed to chemicals, oils or other caustic substances that aggravate your skin, please list them below
Do you

Sun batheUse a tanning bed
If so, how often
Have you ever had

BotoxFillerPeelsFacial surgeryLaser resurfacingCollagen injections
If so, how recently
Does your skin heal fast

YesNoI scar easilyProne to hyperpigmentation
Do you get sores/blisters (Herpes Zoster/Shingles)

YesNo
Have you ever used

AccutanePrescription Retinoid/RetinolAny other prescription medication for skinNone
What Oral medications do you take, if any
What medicated ointment/creams/lotions do you currently use
Any personal or family history of skin cancer?

YesNo
How would you describe your overall health

ExcellentGoodFairPoor
Have your ever had any of the following, past or present

AcneAllergiesArthritisHigh or Low Blood PressureBreast ImplantCancerCataractsHigh or Low CholesterolClaustrophobiaDiabetesEczemaEpilepsyHay FeverHeadachesHeart Disease/ConditionsHepatitisHIV/AIDSLupusMenopausalMetal ImplantsPace MakerPhlebitis
If you get a pimple, do you pop it?

NeverAlwaysSometimes
Do you wear sunscreen

EverydayOnly in the summerSometimesNever
Do you drink

Yes, OftenYes, OccasionallyNo
Do you smoke Cigarettes

Yes, OftenYes OccasionallyNo
Have you had a reaction to

CosmeticsMetalsMedication
If so, please elaborate
How is your stress level

HighModerateLow
Do you sleep well

YesNo
How many hours of sleep do you get in a day

0-6 hrs7-8 hrs9+ hrs
Do you exercise regularly

YesNo
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

Fast FoodJunk FoodKelpSeaweedSugary FoodsSalty FoodsMilk/CheeseSushiSoyProcessed FoodsWhey ProteinRed Meats
Are you any of the following:

VegetarianVegan
How many glasses of water do you consume daily
How many caffeine-type beverages do you consume daily
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?

YesNo
Do you wear makeup? How often and what kind (Blush, foundation etc.) What brands?
For Women
Are you pregnant or trying to get pregnant

YesNot now but will beNo
Are you experiencing any hormonal imbalances

YesNo
If so, please elaborate
For men
Do you experience skin breakouts or ingrown hair when shaving?

Yes alwaysYes occassionallyNo
What is your facial hair like?

Full BeardClean ShavenGoatee or styled
What do you currently use in your skin routine (check all that apply)

NoneBar soap and waterCleanserTonerSerumsMaskMoisturizerSunscreenExfoliatorRetinolOther
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
Please list all skincare products you currently use (including oral vitamins)
What is most important to you in skincare? (Pick one)

Sensorial Experience (smell, feel)CostEffectivenessClean/NaturalCruelty FreeEco-Friendly
What else is important to you in skincare (check all that apply)

Sensorial Experience (smell, feel)CostEffectivenessClean/NaturalCruelty FreeEco Friendly
What type of skincare routine do you prefer

Very basics (1-3 products)Standard (3-6 products)Elaborate (6 or more)
Do you find it difficult to stick with a routine everyday?

YesNo
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?

YESNON/A
What age did your acne develop

10-1920-2930-3940-4950+N/A
Do you only breakout during your menstrual cycle?

YesNoI do not have a menstrual cycleN/A
What areas of the face do you get breakouts (Click all that apply)

ForheadCheeksJawlineChinNoseHairlineAll of itEarsNeckN/A
Do you suffer from PIE (Red/Purple/Pink marks leftover from acne)

YesNoN/A
Any other skin questions or concerns?
Are you comfortable with your photos being used in social media posts (ie. Before & Afters, testimonials)

YesCropped/Eyes Sensored onlyNo
Please upload photos of your skin. For a quality assessment, take close up photos in multiple angles and under natural lighting.

Cancelof
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.
Signature

Powered by Jotform SignClear
Date of signature

MonthDayYear
Date
Please provide the order number you received in your email
Should be Empty:

Virtual Consultation Form

For Women

For men