Honey B Esthetics | Virtual Skin Assessment
Complete this after purchasing your consultation—share your skin details, routine, concerns, and optional makeup-free photos for your personalized skincare plan.
Client + Service Details
Selected Service
*
The Skin Check $49 (Asynchronous)
Virtual Skin Consultation $89 (30-minute video)
Full Legal Name
*
First Name
Middle Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
State of Residence
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
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
Other
Are you 18 years of age or older?
*
Yes
No
Parent/Guardian Name (if under 18)
First Name
Last Name
Parent/Guardian Consent (if under 18)
I confirm I am the parent/guardian and consent to this assessment.
Skin Profile
Skin type
*
Dry
Oily
Combination
Unsure
Top skin concerns
*
Breakouts
Post-breakout marks
Hyperpigmentation
Dryness
Sensitivity
Redness
Texture
Aging
Other
What are your top two skin goals?
*
Fade dark spots / even skin tone
Fewer breakouts
Better hydration
Strengthen skin barrier / reduce sensitivity
Smoother texture
Reduce the appearance of fine lines
More consistent routine
Other
Other
History / duration of concern(s)
*
Additional context
Current Routine + Product Use
AM routine - Brand names used
AM routine - Product names and steps
PM routine - Brand names used
PM routine - Product names and steps
Active ingredients used and frequency
Retinoids
Tretinoin
Benzoyl peroxide
Acids (AHA/BHA/PHA)
Hydroquinone
Exfoliants
Other
Sunscreen brand and SPF
Sunscreen use frequency
Please Select
Daily
Most days
A few times a week
Rarely
Only when outdoors
Never
Other
Current prescribed skin products and anything you'd like us to know about your routine or skin
Skin History, Sensitivities, and Medical Safety
Known allergies or sensitivities
Fragrance
Essential oils
Retinoids
Salicylic acid
Alpha hydroxy acids (AHA)
Beta hydroxy acids (BHA)
Niacinamide
Lanolin
Latex
Adhesives
Preservatives
Other
Previous skin reactions or adverse responses
Diagnosed skin conditions (informational only)
Acne
Eczema
Rosacea
Psoriasis
Melasma
Dermatitis
Hyperpigmentation
Dry skin
Oily skin
Other
If you selected any diagnosed skin conditions, please share any helpful details
Are you currently pregnant or breastfeeding?
Not pregnant or breastfeeding
Pregnant
Breastfeeding
Prefer not to say
Recent skin procedures or treatments
Facial
Chemical peel
Laser treatment
Microneedling
Dermaplaning
Waxing
Injectables
Surgery
Other
Are you currently experiencing active skin irritation, open/broken skin, or any urgent symptoms that should be reviewed by a licensed healthcare professional?
No
Yes
Budget, Shopping Preference, and Shipping State
Product budget
*
Please Select
Under $100
$100–200
$200–350
$350–500
Flexible
Would you like to purchase optional products from Honey B?
*
Yes
No
Maybe
Shipping state
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
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
Other
Photo Uploads + Consent
Front Face Photo
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Left Side Photo
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Right Side Photo
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Photo Use Consent
*
I consent to my photos being used to assess my skincare needs and understand they will not be used for marketing without separate approval.
Secure Handling Consent
*
I consent to my photos and personal data being handled securely and accessed only by authorized staff.
Marketing Messages (OPTIONAL)
Yes, I’d like to receive promotional emails and/or texts from Honey B Esthetics. This is optional and not required to receive a consultation or any Honey B Esthetics service.
Permission to Use My Photos for Marketing (OPTIONAL)
Yes, I give Honey B Esthetics permission to use the photos I submit for promotional content on social media, website, or advertising.
Acknowledgments
I understand that virtual esthetician guidance is for cosmetic education only and is not medical diagnosis or treatment.
*
I understand
I understand that results are not guaranteed.
*
I understand
I understand that any medical concerns should be directed to a licensed healthcare professional.
*
I understand
I understand that the consultation price excludes products and that product totals may vary.
*
I understand
I understand that I will receive a customized routine and invoice after my assessment.
*
I understand
Submit Assessment
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