Virtual Evaluation Form

Name

First NameLast Name

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

Birthdate

Date

How'd you find me?

Please upload a photo of your current regimen, even if you don't use it often*

Please upload a 3 photos of your skin free from make up. One from the right side, one from the left side, and one straight on.

If you could change anything about your skin, what would it be?

What, if anything have you done about this so far?

Are you under the care of a dermatologist or physician?

If yes, please elaborate

How would you describe your overall health?

Do you take vitamins, minerals or protein supplements?

If yes, what ones?

Do you smoke (anything) or vape?

Do you exercise regularly?

If yes, what type and how many hours a week?

What kind of work environment do you work in?

How often do you drink alcohol in a week?

How many glasses of water do you drink per day?

Are you vegetarian or vegan?

Do you restrict sugar in your diet?

How high is your stress level?

What cleanser(s) do you use? Please be specific

What Toner(s) do you use? Please be specific

What serum(s) do you use? Please be specific

What moisturizer(s) do you use? Please be specific

What mask(s) do you use? Please be specific

Type a question

What Exfoliant(s) do you use? Please be specific

What SPF(s) do you use? Please be specific

What other products do you use?

Do you take any medication, if yes please list all medications.

Have you ever had a fever blister/cold sore?

Have you ever had acne?

Do you have rosacea

Do you suffer from allergies? Please put "N/A" if no allergies.

Have you ever had a reaction to:

Do you have any of the following:

Are you taking oral contraceptives?

Any other form of birth control?

Are you pregnant, trying to get pregnant, or breast feeding?

Do you experience:

Do you blush easily?

What are your skin concerns?

Your eyes:

Does your skin...

Are you doing treatments with a current esthetician or nurse?

Please describe your tanning history.

Do you have a preference or things we should know about the treatment, or process in general?

PLEASE READ THE FOLLOWING AND AGREE
ALTHOUGH EVERY PRECAUTION WILL BE TAKEN TO ENSURE YOUR SAFETY AND WELL-BEING BEFORE, DURING, AND AFTER YOUR TREATMENT, PLEASE BE AWARE OF THE FOLLOWING INFORMATION AND POSSIBLE RISKS.

Getting treatments with Overt Beauty BarIt may be necessary to recommend alterations and/or additions to your home care regimen. We will recommend the appropriate schedule for future facials/treatments or referrals in order to achieve your skin improvement goals.Please understand it will take a series of treatments to achieve optimal skin health. you will notice subtle changes over time in compliance with your skincare regimen, monthly facials, diet, and lifestyle changes. 80% of your success is on you doing the work outside of the treatment room!

I will not use any other products that have not been approved by my esthetician while I am on their regimen. Nor will I change the regimen given to me by my esthetician without notifying or consulting with them first.

I will inform my esthetician of any medication/supplements that I start taking while on their regimen.

I understand that possible side effects include, but are not limited to: mild to moderate redness, mild to moderate peeling/flaking, stinking, dry skin, pimples, cold sore or allergic reaction.*

I will contact my esthetician of any complications or concerns I may have as soon as they occur.

For women, I will inform my esthetician if I get pregnant.

I consent to photographs, and videos being taken for esthetic education, training, professional publications, or sales purposes.

I understand that my esthetician at Overt Beauty Bar will take every precaution to minimize or eliminate negative reactions as much as possible. In the event I may have additional questions or concerns regarding my treatment or products, I will consult my esthetician immediately. I agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosures. I certify that I have read and fully understand the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand and accept that there are potential risks. I do not hold my esthetician at Overt Beauty Bar responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment(s) performed.

I understand that my esthetician at Overt Beauty Bar will take every precaution to minimize or eliminate negative reactions as much as possible. In the even I may have additional questions or concerns regarding my treatment and/or products, I will consult my esthetician immediately. I agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosures. I certify that I have read and fully understand the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand and accept that there are potential risks. I do not hold my esthetician at Overt Beauty Bar responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment(s) performed.

Signature

Date

My Products

Online Evaluation

$50.00 Quantity

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