Virtual Skin Analysis Form

Full Name*

First NameLast Name

Email Address*

example@example.com

Phone Number*

Please enter a valid phone number.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Do you have any of the medical conditions, or are currently being treated for any of these health concerns? Check all that apply:*

If yes to any of the listed above, please explain - answer none of the above if none : *

Are you currently taking any antibiotics, or steroids?*

Are you pregnant, nursing, or planning to become pregnant? *

Are you under the care of a medical provider, or aesthetician? If yes please explain: *

In a short paragraph, please describe your main concerns + how we can best help you : *

Please check all that apply that you are wanting to work on or currently dealing with-*

Describe Your Current Skin Routine and Concerns- what are you loving? What are you not loving?*

Was there any products or brands you see on our shop site that you were interested in? If yes please state which: *

How many steps do you prefer in your routine? Simple, moderate, or no limit?*

How long have you been using your current routine? *

Do you like having at home treatment products? Example- face masks or at home treatment peel pads, etc. Answer no if you are wanting simple. Yes if you are looking for at home enhancements. *

What are your short + long term goals for your skin? Do you have any specific life events you are on a timeline for? (Example/ wedding, graduation, a goal date?)*

Have you ever had any reactions to any specific ingredients, products, or facial treatments? If yes, please explain *

Are you interested in person treatments at Meraki skin? Or just virtual? :)*

Have you ever used any form of retinol? If so, how did your skin respond? *

Please list all supplements + prescriptions you are currently taking: *

In well lit, natural sunlight please upload 3 images of your skin. Left, right, and front. No makeup, please.*

If acne is a concern, please upload a photo of all of your makeup you are using —

Have you or are you currently taking accutane?*

Do you drink high levels of caffeine or energy drinks? Please explain : *

What is your average alcohol consumption per week? *

Do you wear sunscreen daily? How much sun exposure do you get on a regular basis? *

Do you smoke, or vape?*

Do you use tanning beds? *

Are you exposed to high levels of sun on a daily basis?*

What is your activity level like? Mild, moderate, or active? *

Are you currently taking any form of birth control? If yes, please start which form *

What is your stress levels like? Low, moderate, high?*

Do you notice any changes in your skin around your menstrual cycle? *

Do you have any allergies or sensitivities to smells, fragrance, etc? *

What is your budget for your new skincare routine? We have access to lots of products to assure we have something attainable for everyone:)*

Meraki Skin & Beauty – Virtual Assessment Terms & Conditions

By booking and/or purchasing a Virtual Skincare Assessment with Meraki Skin & Beauty, you agree to the following terms:

Assessment Disclaimer

Virtual skincare assessments are for educational and informational purposes only. Recommendations are based on the information you provide.
Meraki Skin & Beauty is not liable for any adverse reactions or results. Always discontinue use of any product if irritation occurs and consult a licensed healthcare provider for medical concerns.

Product Purchases
All product sales are final. We do not accept returns, exchanges, or issue refunds once an order has been placed.
Meraki Skin & Beauty is not responsible for lost, stolen, or damaged packages once they have been shipped and tracking has been provided.

Shipping & Delivery
Orders will be shipped to the address provided by the client. Please double-check your information before submitting.
Meraki Skin & Beauty is not responsible for delays due to carriers, weather, or other circumstances beyond our control.

Client Responsibility
By participating in a virtual assessment and/or purchasing recommended products, you acknowledge that you are responsible for following product instructions and disclosing any allergies, sensitivities, or medical conditions.

Skincare results vary per individual. Meraki Skin & Beauty does not guarantee specific outcomes.

My Products*

Basic Skin EvaluationIncludes skin analysis and personalized recommendations. Products are purchased separately.

$65.00 Quantity

Total

$0.00

Credit Card

Digital Signature*