Virtual Evaluation Intake Form

Virtual Client Intake Form
How it works:

This is a Telehealth style skin evaluation. Complete form, upload photos and submit payment. Once submitted, Haley will evaluate your concerns and curate a customized treatment plan + professional skincare routine that can be done at home. You will receive this info within 24-48 hours of submission, via email.
Name*

First NameLast Name
Preferred Name/Nickname or Pronouns
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
First tell me in your own words what I can do to help you feel better about your skin. Please be specific as possible and provide full skin history. The more we know the more we can tailor a plan to your specific needs. *
What are your short and long-term goals for your skin. Short-term meaning what are your expectations today and long-term meaning where do you want to be at the end of your treatment plan? *
Check all skin concerns that you'd like help addressing:*

Texture / SmoothnessAcneBlackheadsLarge PoresOilinessDrynessFine Lines / WrinklesRedness or RosaceaHyperpigmentation / Dark MarksPIE / Red or Purple ScarringPremature AgingFirmness / ElasticityOther
If other, please explain:
List all current products you are using at home in your skincare routine. As well as what you like and dislike about your current routine. *
Upload a photo of the current products in your skincare routine.

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How much are you currently spending on this skincare routine?*
How long have you been doing this routine?*
Have you achieved your desired results with your current routine?*

YesNo
On a scale of 1-10 how do you current prioritize your skin health and where would you like to be? Ex. I'm currently at a 3 with prioritizing but would like to get to an 8 with your help. *
List all current prescriptions and over the counter supplements that you're taking.*
Are you currently, or have you even been on Accutane?*

Yes, currentlyNoYes, but stopped 6+months agoYes, but it has not been 6 months since stopping
Are you pregnant, nursing or planning to become pregnant?*

Currently PregnantCurrently NursingCurrently trying to conceiveGoing to start trying to conceive soon
Are you currently on birth control?*

YesNo
Are you currently undergoing hormone therapy replacement?*

YesNo
Are you currently under the care of a Dermatologist or other Skin Professional for the same concern you previously listed?*

YesNo
Have you ever been under the care of an Aesthetician or Medical Injector?*

YesNo
Please list your history of any facials, injectables, lasers, chemical peels, microneedling, etc. As well as what you did and did not like about these treatments.*
Are you currently wearing Sunscreen daily?*

YesNoOnly when I know I'll be outside
Do you prefer a tinted or nontined SPF?*

TintedNontintedNo Preference
Have you ever used a Retinol before? Was it OTC or Prescription? And what was your experience like with retinol use? *
How many steps is your ideal skincare routine?*

4-55-77-10I will do whatever is required to reach my skin care goals.
What is your budget for starting a new skincare routine?*

200-250250-350350-400I'm willing to invest whatever it may take in order to reach my skin care goals.
Although we do not accept or run insurance, we do accept payment for professional skincare using FSA, HSA and Care Credit. Will you be using one of these for payment?*

FSAHSACare CreditSelf Pay
Do you see yourself coming in studio for treatments with Haley?*

Yes, I live locally but want to start with my routine before coming in.No, I just want to work on my skin from home with my routine.No, but I am open to treatments that can safely be done from home.No, but I may need on going virtual support and possible check ins.
Any specific questions for Haley or other concerns we should know about that pertain to your skin or medical history? *
Did you see any products or homecare treatments that you were interested in at Freckled Skin? *
Please upload 3 clear, well lit, in indirect sunlight, images of each side and the front of your bare, clean face. Starting with Straight on. *

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Left Profile*

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Right Profile*

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If acne, texture, or congestion prone please upload a picture of your current makeup routine.

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List any known allergies or known sensitivities that cause a reaction: *
Do you have any of the following conditions?*

CancerCirculation DisorderClaustrophobiaDiabetesEczemaPsoriasisRosaceaLupusAutoimmune DisorderOther
If other, please explain:
Policies + Liability at Freckled Skin Studio

1. We will not treat clients with questionable medical conditions such as Herpes Simplex (active cold sores, fever blisters), open wounds or sores, healing incisions, infectious diseases, etc. We do not manage clients undergoing cancer, diabetes, or systemic treatments of any specific contraindications for the body.

2. Current clients - We require a minimum of 48 hours advance cancellation notice. Any client giving less will be charged 50% of the service fee. Any clients who No Call + No-Show their appointment will be charges 100% of the service fee. We will not make acceptations under any circumstance including illness.

3. A valid card must be saved on file to reserve your appointment and we will only accept payments from card that is saved on file. Removing your card or adding an invalid card will result in all appointments being canceled and booking to be restricted.

4. I understand that services received here are not a substitute for MEDICAL CARE and any information provided by the Aesthetician is for educational purposes only.

5. All information received by the client on this chart, is completely private and confidential.

6. Children are not allowed at any appointment. This is for the safety of our space and the safety of others. If you arrive to your appointment with your child, the a atment will be canceled, and you will be responsible for the late cancelation fee. We will not make acceptations under any circumstance.

7. All packages purchased in person or online must be used within 6 months of purchase date. Late cancelation fees and no-show fees will be deducted from packages if applicable

8. Multiple consecutive cancelations and or reschedules will result in booking access being restricted.

9. After 2 consecutive Cancellations, No Shows or Reschedules booking opportunities will close indefinitely. Invoice are non refundable under these circumstances.

10. ALL SALES (including invoices) ARE FINAL ONLINE AND IN PERSON. **Virtual Skin Evalutation are not an appointment that can be rescheduled so they are not refundable.

- Freckled Skin Studio cannot be held responsible for any lost or missing items. Please contact the selected carrier (USPS) for assistance making an insurance claim.

- We do not accept any returns or exchanges regardless of circumstance. If an item is defective or broken, please email thefreckledaesthetician@gmail.com with videos/pictures so we may contact the company.
Freckled Skin will take every precaution to ensure your safety and well-being throughout your treatment plan. Please review the following information regarding potential risks and confirm your understanding of the process.

I consent to and authorize Freckled Skin to perform the scheduled treatment and/or homecare oversight.

I voluntarily agree to proceed with the treatment plan and/or homecare guidance after receiving an explanation of its nature, purpose, and associated risks.
While it is not feasible to list every possible risk and complication, I have been informed about the potential benefits, risks, and complications related to the treatment.

I acknowledge that it is essential for my health and safety to provide all requested information in the Client Intake Form(s). I have disclosed my health history, including any relevant conditions, allergies, medications, supplements, or prescriptions I am currently taking (both orally and topically), as well as any past reactions to products or medications.

I recognize that no specific results are guaranteed and that I may need additional treatments and/or homecare guidance to achieve the desired results.

I have read and understood all pre-treatment and home care instructions and recognize the importance of adhering to these guidelines. If I have any further questions or concerns about my treatment plan, I will consult with the team at Freckled Skin promptly.

I acknowledge that if I have any concerns, I will discuss them with the team at Freckled Skin before proceeding with the treatment and/or homecare we've discussed. I understand that Freckled Skin will take all necessary precautions to minimize any negative reactions. This document represents complete disclosure and overrides any previous verbal or written agreements. I confirm that I have read and fully understand the information provided and have had the opportunity to ask questions. I comprehend the procedure and accept the associated risks. I do not hold Freckled Skin responsible for any pre-existing conditions that were not disclosed at the time of this oversight.

I acknowledge and agree to the terms of this liability waiver.
Signature*

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Virtual Skin Eval
$49.00 Quantity

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$0.00
Cost covers your virtual skin evaluation + curation of your professional routine, products are sold seperately.

Submission without payment will result in automatic deletion of your Virtual Skin Evaluation Request. You will need to submit a new Intake Form with payment.

If further questions are needed by Haley before curating your plan she will contact you via email. https://freckledskin.com/pages/contact
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Virtual Client Intake Form

How it works: