Virtual Evaluation Form

Virtual Evaluation Form
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birthdate

MonthDayYear
Date
How'd you find me?
Please upload a photo of your current regimen, even if you don't use it often*

Cancelof
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.

Cancelof
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?

YesNo
If yes, please elaborate
How would you describe your overall health?

ExcellentGoodFairPoor
Do you take vitamins, minerals or protein supplements?

YesNo
If yes, what ones?
Do you smoke (anything) or vape?

YesNo
Do you exercise regularly?

YesNo
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?

None1 Galss per dayOnce or twice a weekCasually/Socially
How many glasses of water do you drink per day?

1 to 3 glasses4 to 6 glasses7 or more
Are you vegetarian or vegan?

YesNo
Do you restrict sugar in your diet?

YesNo
How high is your stress level?

LowMediumModerateHigh
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?

YesNo
Have you ever had acne?

Yes as of more recentlyYes always haveOnly during menstrual cycleNot AnymoreNo
Do you have rosacea

YesNo
Do you suffer from allergies? Please put "N/A" if no allergies.
Have you ever had a reaction to:

IodineCosmeticsSunscreenPollenMetalMedicationFoodAnimalsFragranceLatexOther
Do you have any of the following:

ClaustraphobiaDiabetes type 1Diabetes Type 2EpilepsyJoint ReplacementHeart Disease or Heart ConditionMenopause/peri-menopause statesHepatitisCancer
Are you taking oral contraceptives?

YesNo
Any other form of birth control?

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

YesNo
Do you experience:

Excessive oily skin during the dayFlakiness or Scaly SkinTightnessRedness
Do you blush easily?

YesNo
What are your skin concerns?

ScarsWrinkles/fine linesPigmentationAgingDrynessEczema, Rashes, AllergiesAcneRednessTexture
Your eyes:

PuffinessDark CirclesDehydratedWrinkles/Fine lines
Does your skin...

Heal quicklyScarsPigments Easily
Are you doing treatments with a current esthetician or nurse?

YesNo
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!

Agree
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.

AgreeDisagree, at my own risk
I will inform my esthetician of any medication/supplements that I start taking while on their regimen.

Agree
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.*

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

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

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

AgreeDisagree
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.

Agree
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.

Agree
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Online Evaluation

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