Virtual Skin Care Consultation

Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Date of Birth*

Date

Email*

example@example.com

Shipping Address (if we are not shipping and you are picking up at office please put "PICK UP"). **SHIPPING: All products purchased are ship out via UPS and cost $10 to ship.*

Please attach at a minimum of 3 photos; left side of face, right side of face, and straight on (selfie). Take pictures in indirect sunlight, facing a window. Face should be makeup free and washed.

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What are your main concerns regarding your skin health?

Drug Allergies

Lifestyle / Hobbies(Are you in the sun frequently, indoors often, etc.)

What kind of skin do you have? (dry/oily/normal/combo)

Daily intake regarding sugar, dairy, gluten(soft drinks, energy drinks, bread, etc)

Current Skin Care

Method to achieve your results

Mild (I don't want any anticipated reactions)Moderate (I am okay with moderate anticipated reactions.)Aggressive ( I want to run to the finish line and am okay with redness, peeling, irritation.)

Now what?

* Once we receive all of the above information, we will then create a regimen customized to your specific needs.

**Before we begin, you will be charged a non-refundable $50 consultation fee. All consultation fees can be applied to same day product or service purchases (minimal $100 purchase required to apply consultation credit). Consultations fees are nonrefundable and may not be applied to any other service or products.

** After we finalize the products you'd like to purchase, you will be invoiced. Your products can be picked up in office or shipped to you for a shipping fee of $10. Please specify if you'd like to pickup or ship if you opt to receive an invoice and not purchase online.

** Your product application and follow up instructions will be emailed to you. Your custom instruction sheet and progress photos will also be uploaded to your TouchMD account to track your progress overtime. All new patients will be sent a welcome email to login to their new TouchMD account after the consultation fee has been paid.

** Please allow for a minimal 7-day response time to all messages due to an increased demand.

We look forward to guiding your way to GLOWING skin!
— Timeless RX Esthetitian's!

Billing information.*

Card number, expiration date, security code