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Name* This field is required.
First Name
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Address* This field is required.Please tell me where you're from...
Street Address
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Please share your Email* This field is required.I will use this as a form of communication with you and will not abuse your email.
example@example.com
Confirm Email
4
Would you like to be added to my email list for specials and other skincare information?* This field is required.
Yes
No
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Mobile Phone Number* This field is required.Please use a text capable phone number! Texting is the best way for me to get back to you...
Area Code
Phone Number
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What is the requested date for your appointment?This is a request only and may not result in an appointment at that particular time. I will do my best to accommodate your requested date and you will be offered the next available appointment.
Date
Year
Month
Day
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What is the desired time you are requesting?This is a request only and may not result in an appointment at that particular time. I will do my best to accommodate your requested time and you will be offered the next available appointment.
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2
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Hour
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10
20
30
40
50
Minutes
AM
AM
PM
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Please tell me a little about your skin goals and concerns. Be as descriptive as possible...* This field is required.As a clinical esthetician, I can help you with your skin issues and goals from sensitive to challenging...
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Ok
Ok
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What do YOU think your skin type is?* This field is required.I ask this because we often misdiagnose ourselves (Me included! I was where you are once)...
Normal
Combination
Oily
Dry
Sensitive
Mild Acne
Moderate Acne
Mature and Aging
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What skincare products are you currently using?* This field is required.Be as thorough as possible...
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What makeup products are you currently using?* This field is required.
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Ok
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Lifestyle* This field is required.Does your job or lifestyle require that you work/play outdoors?
Yes
No
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Do you wax your facial skin on a regular basis?* This field is required.
YESNO
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Have you ever had facials, chemical peels, microdermabrasion or any resurfacing treatments?* This field is required.
YESNO
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Have you ever had facials, chemical peels, microdermabrasion or any resurfacing treatments within the past month?* This field is required.
YESNO
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Are you using Retin A?* This field is required.
YESNO
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Are you using Benzoyl Peroxide?* This field is required.
YESNO
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Please tell me about any allergies or sensitivities you have...* This field is required.This is important due to some contraindications with fruits, nuts or medications.
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Ok
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Please tell me about any health issues you may have...* This field is required.
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This next section is a series of yes/no questions relating to your health. Please answer as honestly and to the best of your knowledge.
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Cancer* This field is required.
YESNO
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Circulatory issues?* This field is required.
YESNO
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Arthritis?* This field is required.
YESNO
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Hormonal Imbalances?* This field is required.
YESNO
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Diabetes?* This field is required.
YESNO
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Lactating?* This field is required.
YESNO
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Psoriasis?* This field is required.
YESNO
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Chemotherapy?* This field is required.
YESNO
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High blood pressure?* This field is required.
YESNO
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Hysterectomy?* This field is required.
YESNO
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Thyroid?* This field is required.
YESNO
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Pregnant? * This field is required.Or trying to be?
YESNO
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Recent surgeries?* This field is required.
YESNO
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Eczema?* This field is required.
YESNO
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Rosacea?* This field is required.
YESNO
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Please tell me about any medications you are taking.* This field is required.If none just say none...
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Small
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Accutane?* This field is required.
YESNO
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Antibiotics?* This field is required.
YESNO
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Birth Control?* This field is required.
YESNO
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Take PhotoPlease add a photo for your file...
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Signature* This field is required.I have read and completed this questionnaire. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive are voluntary and I release Kara Vaughn-OConnell, youToepia Day Spa and Kara's beYoutiful.Solutions for skin and nails from any liability.
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