Virtual Skintake Form
Client Name
*
First Name
Last Name
Date of birth
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address (Only if chance of product shipment)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please take a moment to answer the following questions
Check the areas you would like to improve with your skin:
Color
Texture
Freckles
Wrinkles
Eye Area
Firmness
Capillaries
Plumpness
Smoothness
Neck Area
Decollatage
Blackheads
Breakouts
Acne
Premature Aging
Dryness
Pore Size
Congestion
Scarring
Are you or have you ever been on Accutane?
Please Select
Yes
No
Are you presently taking any medications?
Yes
No
If so, please list
Are you taking oral contraceptives?
Yes
No
Please check if you are affected by or have any of the following
Asthma
Cardiac Problems
Depression
Herpes
Fever Blisters
Anxiety
Epilepsy
Skin Disease
Hepatitis
High Blood
Pressure
Sinus Problems
Immune Disorders
Lupus
Eczema
Hysterectomy
List any herbal supplement and vitamins:
Are you pregnant?
Please Select
Yes
No
Trying
Nursing
Do you smoke?
Yes
No
Have you had skin cancer?
Yes
No
Do you have any allergies to cosmetics, foods or drugs?
Yes
No
Please specify
Please list all skincare products you are currently using:
Have they achieved the results that you want?
Please Select
Yes
No
Do you wear sunscreen daily?
Please Select
Yes
No
How much are you currently spending on skincare per month?
On a scale of 1-10, how serious are you about your skincare journey? (10 meaning its your top priority!)
Please Upload high quality phots of your face, taken in natural light. One front facing photo, and one of each side of your face.
I agree with
If I experience any pain or discomfort during the session, I will immediately inform the esthetician so that the products and/or technique may be adjusted to my level of comfort.
I further understand that facial should not be construed as a substitute for medical examination, diagnosis, or treatment.
I understand that estheticians are not qualified to perform, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such.
I agree to keep the esthetician updated as to any changes in my medical profile during the session and understand that there shall be no liability on the estheticians part should I fail to do so.
I understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session.
Also I understand that;
The services offered are not substitute for medical care, and any information provided by the therapist is for educational purposes only and not diagnostically prescriptive in future
Client Signature
Date
-
Month
-
Day
Year
Date
Save
Submit
Submit
Should be Empty: