Virtual Skincare Consultation Form

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Address You Will Like Your Items Mailed To*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How did you hear about Revive Glam Studio?*

What are your primary skincare concerns or goals? *

Have you experienced any recent changes in your skin condition?*

How would you describe your skin type?

If Please explain to the best of your ability*

Do you have any ongoing medical conditions that may affect your skin (e.g., eczema, psoriasis, acne)?*

YesNo

Have you ever been diagnosed with skin cancer or other skin-related conditions?*

YesNo

Do you have a history of excessive sun exposure or sunburns?*

YesNo

On average, how much water do you drink per day?*

How many hours of sleep do you typically get per night?*

Do you smoke or vape?*

YesNo

How would you describe your lifestyle? Do you eat healthy, work out, play sports etc*

How would you describe your gut health?

Do you use fabric softener or fabric softener sheets in the dryer?

YesNo

Do you swim in a chlorinated pool?*

YesNo

Do you work around chemicals, tars, oils, grease or inks?*

YesNo

What is your occupation?

Do you work overnight?

YesNo

How often do you consume alcohol?*

Rarely/NeverOccasionallyRegularly

How often do you wear sunscreen or sun protection?*

DailyWeeklyOccasionallyRarely

Are you currently experiencing any skin irritation, inflammation, or discomfort?*

YesNo

What is your current skincare routine? Please list all products you use regularly: (YOU CAN TAKE A PICTURE AND INCLUDE THEM BELOW JUST WRITE PICTURE INCLUDED HERE)*

Type Picture if you want to submit one below

Upload a pic of your products if you don't want to list them all above (line them up in order of use to try to get as less pictures as possible.)

Do you use Retin-A, Renova, Adapalene, Hydroxyl Acid, or Retinol/vitamin A derivatives?*

YesNoNot Sure

How often do you use exfoliating products?*

Daily2-3 times per weekOnce a weekRarely/Never

Are you open to trying new brands/products?*

YesNo

Are there any specific skincare ingredients or treatments you are interested in learning more about?*

Do you prefer specific types of products (e.g., organic, fragrance-free, cruelty-free)*

Are you currently taking any medications that may affect your skin?*

Yes (Please Specify Below)No

Please specify the medications you are taking that may affect your skin.

Have you ever used prescription skincare products or treatments?

Are you currently using any hormonal contraceptives (e.g., birth control pills, hormonal IUD)?

Are you currently pregnant or breastfeeding?*

YesNo

Do you have any known allergies to skincare ingredients or products? If yes please specify, if not just say no*

Do you have a history of allergies to food, medications, or other substances? If yes please specify, if not just say no*

Are you currently taking any supplements or herbal remedies that may affect your skin? List them even if you don't think they affect your skin.

Have you had any previous professional skincare treatments or procedures?*

YesNo

Have you experienced any skin reactions or sensitivities to products in the past?*

Have you ever had a reaction to skincare products or ingredients in the past?*

Have you had a reaction to anything, including food, products or seasonal?

Have you had any professional skincare treatments in the past 3 months?

Have you recently used any self-tanning lotions, creams, or treatments?*

YesNo

Have you experienced Botox, Restylane, or Collagen injections?*

YesNo

Do you perform any at home treatments or in person facial treatments?*

Have you ever used an acne medication? If Yes, when and which drug?

Have you had any facial treatments in the last 90 days?

Is there anything else you would like the esthetician to know to ensure a successful consultation experience? *

May we contact you via email about future promotions and news?*

YesNo