Virtual Client Intake Form

Full Name

First NameLast Name

Email Address*

example@example.com

Phone Number*

Please enter a valid phone number.

Date of Birth*

Date

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:*

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.*

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?*

NoYes

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 conceiveNone of the above

Are you currently taking 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 skincare goals

What is your budget for starting a new skincare routine?*

200-250250-350350-400I am willing to invest whatever it may take in order to reach my skincare goals

Do you see yourself coming in studio for treatments with Eilis?*

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 Eilis or other concerns we should know about that pertain to your skin or medical history?*

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. *

Left Profile*

Right Profile*

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

List any known allergies or known sensitivities that cause a reaction:*

Do you have any of the following conditions?*

If other, please explain:*

Policies + Liability at Skin By Eilis

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 treatment will be canceled, and you will be responsible for the late cancelation fee. We will not make exceptions under any circumstance.

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.

- Skin By Eilis 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: eilis@skinbyeilis@gmail.com with videos/pictures so we may contact the company.

Skin By Eilis 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 Skin By Eilis 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 Skin By Eilis promptly.

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

If further questions are needed by Eilis before curating your plan she will contact you via email. https://skinbyeilis.com/pages/contact

My Products

Virtual Skin Eval

$49.00

Total

$0.00

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