Online Virtual Consultation Form

Virtual Consultation

Simply fill out this form to get started!
Personal Information:
Name

First NameLast Name
Age
Phone Number
Please enter a valid phone number.
E-mail
example@example.com
What is the best way to contact you?*
Questions and Details:
How would you describe your skin?

DryOilyNormal to dryNormal to oily
What is your main concern with your skin? Please pick only one.

Controlling breakoutsFading brown spotsFine lines and wrinklesPitting acne scarsGeneral anti-aging/prevention/healthy skin
*OPTIONAL* What is your second concern with your skin? Leave blank or pick only one.

Controlling breakoutsFading brown spotsFine lines and wrinklesPitting acne scarsGeneral anti-aging/prevention/heathly skin
How sensitive is your skin?

Very sensitive - products often burn and cause discomfortModerately sensitive - occasionally products burn or cause discomfortResilient - rarely experience sensitivity
Do you have the tendency to breakout with pimples?

Yes, I frequently have pimples on my face.I have occasional breakouts.I tend to breakout near my cycle only.No, I never/almost never have a pimple.
Accutane history

Currently taking Accutane/IsotretinoinHave never taken Accutane/IsotretinoinStopped Accutane/Isotretinoin greater than 6 months ago
Are you currently using retinol, Retin-A, tretinoin, Renova, Differin, or any other similar product?

YesNo
Please describe your sun exposure habits. How much time do you spend in the sun on a daily basis? Weekends, boating, outdoor activities such as baseball games, etc.
Are you willing to go through some peeling/flaking/redness to achieve your results?

Yes! I'll do whatever it takes to get maximum results.I would like as little peeling/flaking/redness as possible.
If you are local to the Morgan City area and/or are able to come to our office, would you like recommendations on services that would help you achieve your goals?

YesNoN/A I am not local/unable to attend in office appointments.
Are you pregnant?

YesNoCurrently trying to get pregnant
***Please let us know if you become at any point as we will have to adjust what products you can safely use.***
Are you breastfeeding?

YesNo
Please list any allergies:
If you are under the care of a physician, please briefly explain below.
Is there anything else you'd like me to know about your skin?
*OPTIONAL* Upload a picture of your skin in natural lighting. This will help me make the best recommendations for your skin.

Cancelof
We strongly recommend going over your recommendations by either phone call or video call; however, this is not required. How would you like to receive your recommendations?

Video call, followed by an email with details of the call.Phone call, followed by an email with details of the call.Email recommendations only.
Signature | Please allow 3 business days for your consultation results to be completed.

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