Virtual Consultation Form

Virtual Consultation Form

Share your skin concerns and goals for personalized guidance
Client Information
Full Name

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth or Age

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address to ship products

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Time Zone
Best Contact Method

Other
Goals & Primary Concern
What is your #1 skin concern?

Other
How long has this been going on?
What does “success” look like in 30 days?
What does “success” look like in 90 days?
Photos & Zoom Requirements
Upload photos (front, left, right + close-up of problem areas)

Cancelof
Photo Instructions:- No makeup, no filters- Bright natural light or facing a window- Avoid heavy shadows (“no cast” on face)- Hair pulled back- Take at same time of day if possible for progress
Zoom Call Requirements (please acknowledge):
Current Routine & Products
Cleanser (name)
Moisturizer (name)
SPF (name + how often used)
Actives (retinol, acids, benzoyl peroxide, adapalene, etc.)
Anything that burns, stings, or dries you out?
Have you recently changed products (in the last 2–4 weeks)?
Triggers & Lifestyle
Known triggers (select all that apply):

Other
Supplements (vitamins, probiotics, pre-workout, etc.)
Do you work-out? How often? Do you wipe down equipment / touch face?
Top 5 foods you eat most weeks
Dairy intake
Sugar intake
Optional: Food journal (any frequent foods in last 2 weeks)
Skin & Health Safety
Do you have any health concerns or medical conditions I should be aware of that could affect your skin or your ability to use certain skincare ingredients/products?
If yes, please explain
Please check any of the following (current or past) that may impact skincare recommendations:
Are you currently using any medications that may affect your skin (examples below)?
Examples (for their clarity—optional to include):
- isotretinoin/Accutane (current or within last 12 months)
- topical tretinoin/retinoids
- antibiotics for acne
- steroids (topical/oral)
- blood thinners
- photosensitizing meds
Allergies/sensitivities (especially to fragrance, acids, benzoyl peroxide, etc.)
History of eczema, rosacea, or dermatitis?
Have you seen a dermatologist? Any diagnosis?
Do you pick at your skin?
Consent & Disclaimers
Consent to Consult: I understand this is educational skincare guidance and not medical diagnosis or treatment.
Product Reaction Policy: I understand irritation can occur with any product and I agree to stop use and notify Dani Esthetics if I experience burning, swelling, rash, or severe discomfort.
Client Acknowledgement. I confirm the information I provided is true and complete to the best of my knowledge. I understand that skincare recommendations depend on the accuracy of the information shared. Dani Esthetics is not liable for adverse reactions or outcomes related to incomplete, inaccurate, or withheld information, including undisclosed health conditions, medications, allergies, or pregnancy/breastfeeding status.
Photo/Video Marketing Release:
Progress Tracking Release:
Communication Consent: I consent to receive follow-up messages related to my consultation and plan (email/text/DM).
Type your full name as signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Virtual Consultation Form

Client Information

Goals & Primary Concern

Photos & Zoom Requirements

Current Routine & Products

Triggers & Lifestyle

Skin & Health Safety

Consent & Disclaimers