Virtual Consult - Your 6 Month Skin Transformation
Please take a few moments to complete the form below with honesty. Your responses allow us to understand your unique skin concerns and create a personalized plan tailored to your needs.Once submitted, Katie will reach out within 24–48 hours to schedule a phone consultation. During this call, she will review your responses, ask follow-up questions, and create a custom PDF outlining your personalized skincare regimen and professional tips. Consultation Details:Cost: $200 ($150 credited towards recommended skincare products on website that we will place day of + free shipping) This 6 month program featuring 5 follow up calls to provide ongoing support, personalized product recommendations, and close progress tracking with Walk In Grace Esthetics. Our mission is to provide guidance, education, and support to help you feel confident in your skin and achieve lasting results. We’re honored to guide you on your journey to restore, strengthen, and reveal your healthiest glow.
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / 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:
Texture/ Smoothness
Acne
Blackheads
Whiteheads
Oiliness
Dryness
Fine lines / Wrinkles
Redness or Rosacea
Hyperpigmentation
PIE / Red or Purple Scarring
Premature Aging
Firmness
Sensitive
Other
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.
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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?
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, currently
No
Yes, but stopped 6+ months ago
Yes, but it has not been 6 months since stopping
Are you pregnant, nursing or planning to become pregnant?
Currently pregnant
Currently Nursing
Currently trying to conceive
None of the above
Are you currently taking birth control?
Are you currently undergoing hormone therapy replacement?
Are you currently under the care of a Dermatologist or other Skin Professional for the same concern you previously listed?
Have you ever been under the care of an Aesthetician or Medical Injector?
Please provide your history of facials, injectables, Botox, lasers, chemical peels, microneedling, and other skin treatments. Include details about what you liked and did not like about each treatment, as well as how recently you received them.
Are you currently wearing Sunscreen daily?
Do you prefer a tinted or nontined SPF?
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?
4-5
5-7
7-10
What is your budget for starting a new skincare routine?
200-250
250-350
350-400
I’m just looking to add one to two items to start
Do you see yourself coming in studio for treatments with Katie
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 Katie 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.
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Left Profile
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Right Profile
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If acne, texture, or congestion prone please upload a picture of your current makeup routine.
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List any known allergies or known sensitivities that cause a reaction:
Do you have any of the following conditions?
Cancer
Diabetes
Lupus
Eczema
Psoriasis
Rosacea
Autoimmune Disorder
Other
If other, please explain:
Have you had Skin Cancer? If so please describe what type and history of removal.
How often do you eat eggs, dairy, and chicken?
How much water on estimate do you drink a day?
Do you battle with anxiety, depression and or OCD?
Is whey protein, in all forms such as protein bars, etc. in your everyday eating?
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