Virtual Skin Consultation Intake & Consent
Complete your details, skincare history, goals, and upload 3 makeup-free photos to request your $79 virtual consult.
Client Information
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
*
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
City / State
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Preferred Method of Contact
*
Email
Phone
Text Message
Other
Skin Profile
Skin type
*
Normal
Dry
Oily
Combination
Sensitive
Unsure
Top skin concerns
*
Acne/breakouts
Hyperpigmentation/dark spots
Melasma
Dryness/dehydration
Sensitivity/redness
Uneven texture
Enlarged pores
Fine lines/wrinkles
Dullness
Other
Top 3 skincare goals
*
Current Skincare Routine
Morning routine products
*
Evening routine products
*
List any products that have caused irritation or discomfort
*
Describe any other skincare treatments, actives, or prescription products used regularly
*
Skin & Safety History
Known allergies or sensitivities
*
Fragrance
Essential oils
Retinoids
Salicylic acid
AHA/BHA acids
Benzoyl peroxide
Niacinamide
Lanolin
Latex
Adhesives
Sun/UV exposure
Other
Prescription skincare products or medications used on the skin
*
Diagnosed skin conditions
*
Acne
Rosacea
Eczema
Psoriasis
Dermatitis
Hyperpigmentation
Melasma
Seborrheic dermatitis
Hives
Cold sores/Herpes simplex
Milia
Keloid tendency
Other
Are you currently under dermatologist care?
*
Yes
No
Are you pregnant or breastfeeding?
*
Pregnant
Breastfeeding
Neither
Prefer not to say
Recent professional skin treatments
*
Chemical peel
Laser treatment
Microneedling
Injectables
Dermaplaning
Waxing
Other professional treatment
None
History of adverse reactions to skincare products or professional treatments
*
Anything else the esthetician should know before recommendations
*
Skin Photo Uploads
Front-facing 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
Consent to review skin photographs
*
I consent to Marimad Luxury Spa reviewing the skin photographs I submit solely for the purpose of providing my virtual skincare consultation.
Disclaimer, Acknowledgment & Payment
This virtual skincare consultation is for cosmetic and educational purposes only and is not intended to diagnose, treat, cure, or prevent any medical condition. Marimad Luxury Spa and its estheticians are not acting as medical professionals during this consultation. Recommendations are based solely on the information and photographs provided by the client. Results may vary, and no specific outcome is guaranteed. Clients should consult a licensed physician or dermatologist regarding medical concerns, persistent skin conditions, allergic reactions, or other health-related issues.
I have read, understand, and agree to the Virtual Consultation Disclaimer above.
*
I agree
I confirm that the information I have submitted is accurate to the best of my knowledge.
*
I confirm
Virtual Skin Consultation Fee ($79)
*
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Virtual Skin Consultation
Non-refundable virtual consultation fee. No refunds or cancellations after payment.
$79.00
$
79.00
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Cash App Pay
After submitting the form, you will be redirected to Cash App Pay to complete the payment.
Afterpay
After submitting the form, you will be redirected to Afterpay to complete the payment.
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