Skin Care Consultation Questionnaire

The Virtual MedSpa Contact Form - Part I

THANK YOU IN ADVANCE FOR YOUR PATIENCE. Because your privacy is important to us. We follow a two-step process to collect the necessary information we need to provide a comprehensive skin care analysis. This is Part I. Part II will follow immediately upon submitting this Contact Sheet. Please use only your Client Code on Part II. We use a coding system so that no personal identifiable information is combined with your personal health information (PIH) and we maintain contact information separately from treatment and medical information.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
CLIENT CODE*
First name: first 2 letters; Last Name: first 2 letters; Year of birth: last 3 digits; Month of birth: Alphabetic (A-L) and Day of birth (two digits, using 0 if born on 1st - 9th of the month)
FIND YOUR CLIENT CODE: Your unique client code is derived by taking the first two letters of your FIRST name and the first two letters of your LAST name, followed by the YEAR of your birth (use only the LAST three digits), then the MONTH of your birth expressed as an ALPHABET (A-L only), finally, followed by the DAY of your birth (if you were born on the 1st - 9th, add "0" before the day. For example, Client Mary Scott, born on January 1, 1990, will have a Client Code of: MASC990A01
Email*
example@example.com
Phone Number*

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Best way to contact you for appointment reminders and other relevant information from theVirtualMedSpa.com*

TextEmail
Signature

Clear
How Did You Hear About Us? *
If a Facebook Group, please provide Group Name; if an Existing Client, please provide name and/or email; for any other source, please provide specifics so we can thank them!
Should be Empty:

The Virtual MedSpa Contact Form - Part I