Virtual Skin Evaluation

Virtual Skin Evaluation
Please take your time to carefully read and complete the form below. Once submitted, you’ll receive a response from Naked Bliss Esthetics within 24–48 hours.

We hope you find incredible value in this service, and we can’t wait to connect with you!
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
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.)*
In your own words, tell me about your skin: What are your main skin concerns? How long have you been experiencing these concerns? What improvements or results are you hoping to achieve? Is there anything important in your skin history that I should know (treatments, sensitivities, past routines, etc.)? The more specific and detailed you are, the better we can tailor a plan for your specific needs.
Skin Type*
IF UNSURE CHOOSE THE CATEGORY THAT YOU FEEL BEST DESCRIBES YOUR SKIN
AcneHyperpigmentationScarringFine LinesWrinklesLaxityDullnessDehydratedSensitizedReactiveRednessTextureBlackheadsLarge poresOilinessOther
If other, please explain:
Please list all products you currently use at home, including both your morning and evening routines.

For each product, include:
- Product name + brand
- How long you’ve been using it
- How often you use it (daily, weekly, occasionally)
The more detail you provide, the easier it will be to see what's working, what may be contributing to oncerns, and where adjustments can be made.
Products:
Upload a photo of the. Current products in your skincare routine.

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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?
How much are you currently spending on this routine?*
$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.
List all current prescriptions and over the counter supplements that you are taking.*
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.
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*
Yes, currentlyNoYes, but stopped. 6+months agoyes, but it has not been 6 months since stopping
YesNo
If so, please list below
Do you have an ongoing health condition including autoimmune disorders?
YesNo
YesNo
YesNo
Please list any professional skincare treatments you’ve had in the past (such as facials, chemical peels, microneedling, injectables, or laser treatments). As well as what you did and did not like about these treatments.
Anything else we should know about your skin?
Please upload at least 3 clear photos of your skin:

Front facing
Right profile
Left profile

For best results:
- Use natural lighting (facing a window is ideal)
- Remove all makeup before taking photos
- Make sure the image is sharp and unfiltered
- You may also include close-ups of specific areas of concern (optional)
  Minimum of 3 photos required.
Front facing*

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Right profile*

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Left Profile*

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Please list a minimum of 3 days and times that work best for you (all appointments are held via Zoom in Central Standard Time).
Please Note:
- The cost covers your Virtual Skin Consultation and the creation of your customized professional homecare routine.
- Payment must be completed before submitting the form. Your evaluation review will not begin until payment is confirmed.
- If any additional details are needed, we’ll contact you via email.
Thank you for trusting Naked Bliss Esthetics with your skin journey. Once payment is received, we’ll reach out via email or text within 24–48 hours.

Virtual Consultation

Virtual Consultation + Routine

$100.00

Total

$0.00

Credit Card

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