Online Skin Evaluation

Online Skin Evaluation
A consultation and homecare is required for all clients wanting to work with Naked Bliss Esthetics. Consultations are $100 and include the consultation, recommendations, and guidance through your entire skin journey. Products are sold separately.

Please refrain from submitting the form if you are not ready to book.

Complete the form and allow us 24 hours to respond via email to book your consultation. Once you pick your desired time we will send you an invoice for your virtual appointment. Please note, the inovice must be paid in order to secure your appointment.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Birthday*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about us? Google, Instagram, Facebook, Family, Friend? (Please state the name of the person who referred you.)*
Skin Type*
IF UNSURE CHOOSE THE CATEGORY THAT YOU FEEL BEST DESCRIBES YOUR SKIN
Skin Conditions*

AcneHyperpigmentationScarringFine LinesWrinklesLaxityDullnessDehydratedSensitizedReactiveRednessRough TextureBlackheads
Tell us about your skin. Skin concerns, what you’re looking to improve or achieve by working with Naked Bliss Esthetics. How long have you been dealing with your skin concerns if any, etc. Please include any important information of skin history.
How much are you expecting to invest for your homecare routine? Keep in mind that a targeted and tailored regimen begins around $175-$250. We carry multiple products and offer payment plans to ensure we can work with almost any budget.

$175-$250$250-$350$350+I am willing to invest in whatever it may be to get started on a quality and results driven regimen.
Preferred date, time, or day of the week that you’re interested in booking? Please list at least 3. Please note, virtual consultations typically take up to 45 minutes and will be done via Zoom call.
Please list your current full skincare routine. Morning and night along with product names and brands:
Do you like the products you are currently using? What do you like about them? What don’t you like about them? Are you seeing results?
Do you wear sunscreen everyday?*

YesNo
Sunscreen is the most important product in your routine for overall long term skin health. In order to ensure that you enjoy wearing it daily it’s important for us to know what you love or don’t love in a sunscreen. Please write down some characteristics you like or dislike in sunscreens. This will help us pick the right one for you! Examples: Like/dislike glowy, matte, tinted, non-tinted, etc.
Have you ever had any reaction to any product/s or anything you have put on your face?*

YesNo
If yes, what product?
List any other allergies you know of:*
Have you been diagnosed with a skin condition? If so, please list condition*
Are you currently using prescribed skincare/ topical medicines from a dermatologist/doctor?*

YesNo
If so, please list below
Are you or have you been on Accutane within the past 12 months?*

YesNo
Do you have an ongoing health condition including autoimmune disorders?
Please list any current medications and supplements that you are currently taking:
*Women: Are you pregnant or nursing?*

YesNo
Anything else we should know about your skin?
Please upload photos of your skin. Must be in natural lighting and include at least 1 of each: Right profile, left profile, and front facing. You may include close ups of areas of concern.

Minimum of 3 photos are required.
File Upload*

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