Online Consultation Form

Online Consultation Form

*This form is to receive a personalized consultation form with treatment, product and routine recommendations, and more. Please fill out carefully and honestly!
Full Name*

First NameLast Name
Birth Date*

MonthDayYear
Gender*
Email*
Mobile Number
What do you wish to change about your skin? What is your main concern?*
List any current or previous medical history AND any surgical procedures (ex. cancer, heart condition, injectables, etc):
List any prescription or over the counter medications & vitamins or supplements you are currently taking ex: biotin, multivitamin, etc. (this is important!):
List any allergies or sensitivities you may have:
List any prescribed skin medication you are currently using (topical creams or oral medications):
Are you currently pregnant or planning to be in the near future?*
Please list your full current skincare routine (ex: cleansers, moisturizers, serums, spf):*
How would you describe your skin type?*

Oily/Acne-ProneDryCombinationSensitiveNormal
Have you ever been treated for any skin condition by a dermatologist or esthetician?
Have you ever been on Accutane?*

YesNo
How much is your ideal budget for skincare recommendations?

Affordable ($10-20 per product)Reasonable ($20-50 per product)Generous ($50-100 per product)A mix- I'm willing to splurge on great products to fix my concerns, and cut back where I can.
If you answered "yes" to the previous question, when did you last take Accutane?
Upload 5 photos of your face to capture the current state of your skin. Please use natural light by standing outside or near a bright window. (example below)

Cancelof
Signature*

Clear
I hereby authorize and consent Grace Badger to review my form and provide service and product recommendations, and to pay for consultation received.
Please use this link to complete your payment. Please use the first and last name used on the consultation form in the sublect line of your payment. Last 4 of phone number is 7751

VENMO

(price per consultation form is $25)

You will recieve your consultation results via email 3-5 days after recieving payment of your order!
Should be Empty: