Full Name

1
Full Name
First Name
Last Name
2
Date of Birth
Date
Year
Month
Day
3
Biological Sex
Male
Female
4
What is your email address?
example@example.com
5
What’s your phone number?
Area Code
Phone Number
6
Which state do you live in?
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
7
Are you currently pregnant or breastfeeding?* This field is required.
Yes
No
8
This treatment is not recommended for individuals who are pregnant or breastfeeding. A provider will review your intake and follow up if needed.
9
Do you currently have any of the following?(Select all that apply)
Open wounds in the treatment area
Active skin infection
Cold sores
Severe acne flare
Eczema flare
Psoriasis flare
None of the above
10
Are you currently using any prescription skincare products?
Tretinoin
Hydroquinone
Retinoids (other)
Clindamycin
Steroid creams
None of the above
11
Do you have any known allergies to skincare ingredients?(Example: fragrances, retinoids, benzoyl peroxide, etc.)
Huge
Large
Normal
Small
Ok
Ok
12
What are your main skin goals?(Select all that apply)
Improve hydration
Improve texture
Reduce fine lines
Brighten skin
Reduce redness
Fade dark spots
Reduce breakouts
Other
13
How would you describe your skin type?
Normal
Dry
Oily
Combination
Sensitive
14
Do you experience any of the following?
Redness
Dry patches
Flaking
Breakouts
Uneven tone
None
15
Describe your current skincare routine.(Include products you use in the morning and evening.)
Huge
Large
Normal
Small
Ok
Ok
16
Please upload a clear selfie of your face.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
17
Upload a close-up photo of your primary skin concern.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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18
Please upload a photo of your government-issued ID.(Driver’s license or passport)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
19
Telehealth Consent
By continuing, you acknowledge and agree that:
• You are requesting an asynchronous telehealth evaluation from a licensed provider.
• Your provider will review your photos, medical history, and answers before approving or denying treatment.
• This evaluation does not replace an in-person physical exam.
• Your provider may request additional information or decline treatment if it is not safe or clinically appropriate.
• You authorize Outlive Health and its clinical partners to contact you regarding your evaluation and care.
20
I have read and agree to the Telehealth Consent.* This field is required.
☑️ I have read and agree to the Telehealth Consent.
21
HIPAA, Privacy & Communication Consent* This field is required.
☑️ I authorize Outlive Health to securely store my medical intake, photos, and ID for review by a licensed provider. I consent to receive communication (email/SMS) regarding my evaluation and treatment plan.
22
Payment Authorization:* This field is required.
☑️ I authorize Outlive Health to charge $59 upon provider approval.
23
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