Virt. Skin Eval. Form

Virtual Acne Consultation Form
Full Name*

First NameLast Name
Email Address*
example@example.com
Contact Number*
Check the skin condition you'd like to treat:*

Inflamed AcneNon-Inflamed AcneSensitizedPost-Inflamed Red Acne MarksDullnessDrynessOilinessLarge PoresRosaceaCongestionOtherOther
Check the skin type that fits you the most :*

Very DryDryNormalOilyVery Oily
What is your age?*
Are you currently pregnant or nursing?*

YesNo
Do you follow a restricted diet?*

YesNo
Do you smoke or vape?*

YesNo
Do you follow a restricted diet?*

YesNo
Does your lifestyle require 30+ minutes in the sun or sweating?(work,play,drive,activity, exercise*

YesNo
Do you blush easily?*

YesNo
Do you experience a sun burn or only get tan when in the sun?*

YesNo
How often do you consume alcohol?*

DailyWeeklyMonthlyOccasionallyNever
How much plain water do you consume daily?*

1-3cups3-5cups5-8cups8+ cups
Rate your stress level *

1

2

3

4

5

1 is Low, 5 is High
List any allergies*
List any current medications*
List any medical history including autoimmune diseases*
List all the current products you're using (including prescriptions)*
List the makeup products you use*
Describe your skin goals*
Anything else I should know about your skin? (past history, diagnoses, specific concerns etc.)*
Upload Photos of Your Skin (present day)- Must be in Natural Lighting (include at least 1 of each: right profile, left profile, front facing, close up of areas of concern)*

Cancelof
I confirm to the best of my knowledge that the answers I have given are correct and that I have not withheld any information that may be relevant to my service.

Clear

Submit Payment

Skin Evaluation FeeA one-time payment to receive the full benefits of a Brightside Acne Consultation.

$25.00

Enter coupon

Total

$0.00

Payment Methods

Credit Card

Apple Pay

Google Pay

After completing you'll receive:
A detailed skin analysis via email within 48 hrs.
Tailored product recommendations with step by step instructions to treat your skin from home ( detailed steps are provided after product purchase)
Exclusive skincare knowledge based on your unique conditions & goals.
Access to the Brightside Acne Client Portal with product purchase.
Ongoing support from Dezirae
*skincare products purchased separately
Should be Empty:

Virtual Acne Consultation Form

Payment Methods