Virtual Skincare Routine Form
You will receive your results via email in 1-4 business days
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Occupation
How did you hear about us?
Which broad category do you feel best describes your skin?
*
Dry
Normal
Combination
Oily
Check all of the areas you'd like to see improvement in your skin
*
Acne
Blackheads
Pore Size
Texture/Smoothness
Dryness
Oiliness
Scarring from Hyperpigmentation
Scarring (pitted or texture)
Wrinkles/Fine Lines
Plumpness/Firmness
Eye Area
Neck/Chest
Dullness
Skin Tone Evenness
Redness
Other
Have you been diagnosed with any of the following skin conditions?
Rosacea
Psoriasis
Eczema
Perioral Dermatitis
A type of Dermatitis not listed
Melasma
Keloid Scarring
Skin Cancer
Skin Disease
Cold Sores
Please list your current skincare routine:
*
Are there specific products you are interested in adding to your routine?
Do you wear sunscreen every day?
*
Yes
No
Sunscreen is the most important product in your routine for overall and long term skin health. We want to make sure you love wearing it! What are some characteristics you love (or don't) in your sunscreen? (Examples: glowy, matte, tinted, non-tinted, etc.)
Are you, or have you ever been on Accutane?
*
Yes
No
Have you ever experienced a reaction to a skincare product? (If so, please list product)
Are you currently using prescribed skincare from a dermatologist/doctor? (if so, please list below)
Do you smoke (cigarettes/vape/weed)?
*
Yes
No
How are your sleep habits?
*
Rate your Stress Level on a scale of 1-5 (1 being low):
*
How much water do you drink daily?
*
Are you currently pregnancy or nursing?
*
Yes
No
Do you have any known allergies?
Do you have any of the following conditions?
Cancer (or within the past 3 years)
Metal Implants
Thyroid Disorder
Hormonal Imbalance
Hepatitis A/B/C
Depression/Anxiety
Immune Disorder
Menopause
Perimenopause
High Blood Pressure
Low Blood Pressure
Diabetes
Heart Disease
Hysterectomy
HIV/AIDS
Headaches/Migraines
Cervical Spine Dysfunction
Lupus
Fibromyalgia
Circulation Disorder
POTS
Lymphatic Dysfunction
Do you have ongoing health conditions including autoimmune disorders not listed above?
Please list all current medications and supplements (include protein powders, vitamins, etc.)
Do you have any other questions for Ofelia?
Before and after photos are sometimes used for marketing/business purposes to support our business, help attract clientele, and show others how we are capable of helping them just like you! (Please note: we are able to block your features and blur your identity if desired. Your consideration to help our business is immeasurably appreciated.) Would you please consider allowing us to use your photos so that we can portray our work to its fullest? Please choose from the box below:
*
Please Select
Yes! Please use my photos as needed.
Yes, but please crop/blur my identity.
No, I do not wish to have my photos shared.
Please upload clear, well lit photos for us to track your progress. There should be at least one left and one right profile, and one front facing. You may include closeups of areas of concern.
*
Submit Payment
*
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Virtual Skincare Routine
Please allow 1-4 business days for results to be sent to you via email after submission.
$
50.00
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
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