the skin crowd

www.theskincrowd.com
Virtual Client Consultation
Name*
Date of Birth*

MonthDayYear
Phone*

Area CodePhone Number
E-mail*
example@example.com
How did you hear about us?
What would you like to achieve from your virtual consultation?*
Do you have any special skin problems or concerns pertaining to your face or body?*

YesNo
If Yes, please specify.
Are you currently taking any medications?*

YesNo
If Yes, please list them.
Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, or Retinol/vitamin A derivative?*

YesNo
If Yes, please describe.
Have you ever used a prescription acne medication?*

YesNo
If Yes, when? Which medication?
What is your skincare budget?*

$100-$200$200-$300No Budget
What skin care products are you currently using?*

CleanserTonerMoisturizerMaskEye productExfoliatorSerumSPFOther
List brands, if possible
Include a photo of your skin care if you’d like
Which of the following best describes your skin?*

Creamy complexion - Always burns easily, never tansLight complexion - Always burns, tans slightlyLight/Matte complexion - Burns moderately, tans graduallyMatte complexion - Seldom burns, always tans wellBrown complexion - Rarely burns, deep tanBlack complexion - Never burns, deeply pigmented
What is your skin type?*

DryOilyCombinationSensitiveAcne Prone
What areas of concern do you have regarding your skin: Please check any that apply.*

Breakouts/acneBroken capillariesRedness/ruddinessBlackheads/whiteheadsSun spots/brown spotsExcessive oil/shineRosaceaUneven skin toneSun damageDull/dry skinWrinkles/fine linesFlaky skinDehydratedOther
Eyes

DehydratedWrinkles/fine linesPuffinessDark circlesOther
Please submit a few photos of your skin here*
Have you ever had an allergic reaction to any of the following?*

Skincare/CosmeticsAHAs (alpha hydroxy acids)MedicineFragranceFoodDrugsAnimalsPollenSunscreenslodineNoneOther
If Yes, please explain
Have you experienced Botox, Filler or Collagen injections?*

NoYes
If yes, please specify
Are you taking oral contraceptives?

NoYes
If yes, please specify
Any recent changes to or from your contraceptive treatment?

NoYes
If so, what and when?
Are you pregnant or trying to become pregnant?

NoYes
Any menopause problems?

NoYes
If yes, please specify
Are you undergoing any hormone replacement therapy?

NoYes
If yes, please specify
Is there anything else we should know about you?
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 product recommendations that are used. The information I receive here is voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.
Client Signature*

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Date*

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Virtual Client Consultation