One on One Consultation Form

Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Emergency Contact*

Do you consume water on a daily basis, and if yes, how many ounces do you typically intake ?*

How would you describe your skin?*

What are your skin goals? (check all that apply)*

Prevent wrinklesBetter, healthier skinTo address my skin concerns (e.g. acne, hyperpigmentation, rosacea, texture)

What are your skin concerns (check all that apply)*

How old are you?*

Do you wear make-up?*

Do you have a current skincare routine?*

If you answered "Yes or Somewhat" to the question above, what does it consist of? (Check all that apply)

Are you Currently using Benzyol Peroxide?*

YesNo

Have you ever been to an Esthetician or Dermatologist?*

YesNo

Are you currently nursing or pregnant?*

YesNo

Do you tan in the sun or use tanning beds?*

YesNo

Are you currently taking Retin-A/ Retinoids?*

YesNo

Are you currently using Accutane?*

YesNo

Are you prone to cold sore?*

YesNo

Have you had Botox and/ or Fillers in the last 2-3 weeks?*

YesNo

Are you currently taking supplements/ Vitamins?*

YesNo

Are you currently taking any medication?*

YesNo

Please list the medications you are currently taking (If you answered yes to the previous question)

Do you have any medical conditions? If so, please list

Do you smoke or drink? if so how often? *

What skincare line are you currently using? *

Choose a date and time for your Virtual Consultation.

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. I am aware that it is my responsibility to inform the esthetician of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release The Cosmoholic lLC from liability and assume full responsibility thereof.*

Yes, I Understand and agree to the terms & conditions.

Upload Government-Issued ID (Passport, Driver's License, or ID card) If under age of 18 please submit parent/guardian Goverment-issued ID

Signature

Thank You!

I look forward to our consultation! Here are the next steps:

Confirmation: You will soon receive a confirmation email that includes the date and time of our virtual consultation.

Preparation: Before our consultation, please ensure you're in a quiet, well-lit space with a stable internet connection. If you have any specific concerns or questions to discuss during the consultation, feel free to jot them down for a more efficient session.

Consultation: At the scheduled time, I'll connect with you through your chosen platform. We'll delve into your skincare and beauty needs and work on providing personalized recommendations.

Follow-Up: Following our consultation, we will provide you with a summary of our discussion and help you schedule the recommended service.

I'm excited to assist you on your journey to reveal your inner and outer radiance. If you have any questions before our meeting, please don't hesitate to contact me. I'm here to help you feel and look your very best.

Cancellation/Rescheduling:If, for any reason, you need to reschedule your appointment, we kindly request a 48-hour advance notice for cancellations. In the event of no communication or non-attendance at the scheduled virtual assessment for over 15 minutes, your appointment will be canceled, and you'll have to pay for your next consultation. We recognize that unforeseen circumstances can arise and assess each situation on a case-by-case basis.