Online Skincare Consult

Name

First NameLast Name

Phone Number

Area CodePhone Number

Email

example@example.com

Skin Type and Concerns:

What is your skin type? (e.g., dry, oily, combination, sensitive)

Do you have any specific skin concerns? (e.g., acne, wrinkles, redness, dryness)

Current Skincare Routine:

What products do you currently use for your skincare routine?

How often do you cleanse your skin?

Do you use any exfoliating products?

Are you using any moisturizers or serums?

Please list your current products:

Lifestyle Factors:

Do you have any dietary restrictions or allergies that may affect your skin?

Do you smoke or consume alcohol regularly?

Do you spend a lot of time outdoors or are you frequently exposed to environmental factors like pollution or harsh weather?

Medical History:

Do you have any known skin conditions or allergies?

Are you currently taking any medications that may affect your skin?

Have you recently undergone any skin treatments or procedures?

Are you pregnant or trying to become pregnant?

Are you breastfeeding?

Desired Outcome:

What are your primary goals for your skin? (e.g., clear complexion, reduced wrinkles, improved hydration)

Is there anything else you would like to mention or any specific questions you have regarding your skin care?

If you are interested in our cosmetic services, please upload your photos here. We require one frontal photo and photos of both sides of your face. If your concerns are not facial, please upload a photo of the relevant area. Thank you!

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Signature

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this institution and/or skin care profes- sional from liability and assume full responsibility thereof.

Please give us 24-48 hours to get your custom skincare routine to you.

We are not in office Saturdays or Sundays.

Online Skin Care Consultation