Virtual Skin Consultation Form (30 min)

Virtual Skin Consultation Form

Your privacy is very important. The following information is only used to assess your skin care goals, determine what treatments are appropriate for your skin condition and to avoid any possible reactions.
Full Name

First Last
E-mail
We will never SPAM or sell email addresses to third parties.
Phone:
ex. 555-555-5555
Birthdate:
ex. 01/05/1960
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is the best way to contact you?
Who referred you to NOURISH YOUR SKIN by Emmkeo Soul x Beauty?
Are you allergic to anything?
If yes, please list allergies:
Have you been under the care of a physician, naturopathic doctor, dermatologist or any other practitioner within the past year?
If yes, please list reason:
Have you had skin cancer?
If yes, please list area(s):
Do you have any permanent cosmetics or tattoos on the face?
If yes, please explain:
Have you had any of these health conditions in the past or present?
Do you follow a restricted diet?
What is your current level of stress?
List any oral MEDICATIONS you take daily:
List all oral VITAMINS or HERBS you take daily:
Do you currently use any of the following?
Do you currently have any rash, windburn, sensitivites or other issues on the area being treated?
Do you use bleaching creams or Hydroquinone daily?
Does your skin form Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?
Have you used an acne medication?
If yes, please list medication:
Have you had a reaction after having a facial treatment in the past?
Please explain the details:
Have you ever had an ALLERGIC reaction to any of the following?

Other
Female Clients
Are you pregnant or trying to become pregnant?
Do you have Mirena IUD, Copper IUD or other implanted birth control?
Are you taking oral birth control?
Brand name of birth control:
Are you lactating?
Any current menopause problems?
If yes, please explain:
Skin Care History
I offer essential oil free options if you are sensitive, other wise very minimal use in skincare. Do you have a preference?
Do you wear foundation?
When washing my face:
How often do you use a skin regimen?
Do you have an aversion to hot or cold temperatures used on your face?
What conditions would you like to improve?
List any additional conditions you would like treated:
Preparing for your appointment
Please share any products you currently use dusing your virtual appointment, or fill them in below.

Each of the current products will be assessed and discussed during the consultation. Assessment may include some of your original products that are approved for use. Additional and/or replacement products will be added.
Current skin care products you use at home. Include brand names and product names.
Please attach all BEFORE photos in the same lighting, both NATURAL and LED lighting. Front of face, both left and right of entire face profile. Make sure hair is pulled back and away from face.

Browse Files
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What service are you booking or inquiring about? Invoice for emailed report must be paid before receiving.
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 Skin Therapist of my current medical or health conditions and to update this history. The products or treatment I receive here are voluntary and I release NOURISH YOUR SKIN and/or the skin care professional from liability and assume full responsibility thereof.
To cancel an appointment please contact moukda.keo@gmail.com or call 825.438.9222 at least 48 hours prior to your appointment. 50% Deposit will apply to cancellations within 48 hours. Your deposit will be forwarded to your rebooked appointment.
OPTIONAL: I grant permission to NOURISH YOUR SKIN by Emmkeo Soul x Beauty to use photos of my progress for marketing purposes on www.nourishyourskin.co or other business listing pages such as Instagram.
OPTIONAL: I grant permission to NOURISH YOUR SKIN by Emmkeo Soul x Beauty to add me to the email list for promotions and updates about the business.
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