Virtual Evaluation Intake Form

Virtual Skincare Consult
How it works:

This is a Telehealth style skin evaluation. Complete form, upload photos and submit payment. Once submitted, Tina or Hunter 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 24-72 hours of submission, via email.
Name

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

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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:

Other
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?
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?
Are you pregnant, nursing or planning to become pregnant?
Are you currently on birth control?
Are you currently undergoing hormone therapy replacement?
Are you currently under the care of a Dermatologist or other Skin Professional for the same concern you previously listed?
Have you ever been under the care of an Aesthetician or Medical Injector?
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?
Do you prefer a tinted or nontined SPF?
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?
What is your budget for starting a new skincare routine?
Do you see yourself coming in studio for treatments?
Any specific questions for Tina & Hunter 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 Tina Torres Cosmetics?
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?

Other
If other, please explain:
Policies + Liability at Tina Torres Cosmetics

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. 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.

3. 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.

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

5. 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 appointment will be canceled, and you will be responsible for the late cancelation fee. We will not make acceptations under any circumstance.

6. 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

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

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

9. 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.

- Tina Torres Cosmetics 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 hello@tinatorrescosmetics.com with videos/pictures so we may contact the company.
Tina Torres Cosmetics 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 Tina Torres Cosmetics 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 Tina Torres Cosmetics promptly.

I acknowledge that if I have any concerns, I will discuss them with the team at Tina Torres Cosmetics before proceeding with the treatment and/or homecare we've discussed. I understand that Tina Torres Cosmetics 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 Tina Torres Cosmetics 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
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.

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Virtual Skin Eval

$50.00 Quantity

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Virtual Skincare Consult

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