VICTORIOUS ESTHETICS

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Welcome to the beginning of your skin optimization journey!

At Victorious Esthetics, we optimize your skin, helping you achieve your skin health goals by customizing your skin health diet based on your skin type, condition, and goal using natural ingredients and plant alchemy!

We've been researching, creating, and testing customized formulas for live human beings since 2013, with success stories from customers who took a chance on natural remedies and have happily achieved their skincare goals ever since!

This is the beginning of our process and the first step of entry into one of our exclusive Victorious Beauty Health Clubs:

Acne-Fighters

Clarity Seeker

Graceful Agers

Natural Desires Hair Growth Challenge

Sensitivity Soothers

By completing this consultation form, your concerns, goals, and desires can be addressed in your Skin Health Consultation and Professional Analysis.

We can then enroll you in your Skin Health Club and get you started on the path of Skin Optimization!
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Name
First Name
Last Name
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Email
example@example.com
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Date of Birth* This field is required.
If you are under 18, we need your parents' consent to complete this process. Parents your children are welcomed, please be present in all consultations and ordering.
Month
Day
Year
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Phone Number
Please enter a valid phone number.
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ASSIGNED BIRTH GENDER
MALE (XY CHROMOSOMES)
FEMALE (XX CHROMOSOMES)
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Please complete the following statements so that I can better understand the state of your skin and its relationship to your endocrine and reproductive systems.

Please complete as many as you can in reverse chronological order so that I may understand the evolution of your skin.

Do not complete the sentence if you've not yet experienced something on the list.
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Currently, I am Number years old, and ever since I started, * my skin has
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I was years old when I started my menstrual cycle and my skin , eventually at around age my skin became . I've been dealing with every month since I started my period.
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Do you experience breakouts in relation to menstruation
YESNO
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Are You Taking Hormone or Testosterone Replacement Therapy
YESNO
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Are You Pregnant?
YESNO
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Congratulations! How many months?
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When I am pregnant, my skin blanks
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Are you Postpartum?* This field is required.
YESNO
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Congratulations! Well Wishes to you and the new addition to your family! How many months?
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Ever since I had my baby, my skin blanks . I really would like my skin to .
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Occupation
What you do affects your skin!
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Phone Number
Please enter a valid phone number.
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Take PhotoPlease remove make-up and filters, share your bare skin in its' natural condition. You can point out areas of concern if you wish.
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The appearance, and condition of my skin makes me feelHonestly identify your true feelings.
happy and confident!
concerned and embarrassed.
sexy and healthy!
painful and irritated.
abnormal and confused.
hopeless.
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My main skincare concerns are , which seem to result from *
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How would you improve your skin?
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Do you regularly visit a dermatologist or esthetician for your skin?
Yes
No
For Emergency Only
For Relaxation & Skincare
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Dermatologist/Esthetician
We can work closely with your esthetician/dermatologist if you so desire
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If so, what are their directions or suggested medication for your skin condition?
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Please Describe Your Skincare Routine
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Please list the various products you normally use in your daily skincare routine.
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I remove unwanted facial/body hair by Shaving Waxing Threading and I * have ingrown hair.
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My skin is * .
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Do you need help calming your skin sensitivity?
YESNO
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My face produces No Very Little Just Enough Too Much * oil throughout the day.
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My pores are invisible somewhat visible very visible large and deep * field. Please add appropriate blank fields and text.
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Do you have unexplained rashes or dry patches?
YESNO
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Please explain where, when, and how often.
Huge
Large
Normal
Small
Ok
Ok
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Are you experiencing any dramatic change in your skin condition?
YESNO
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Please list any new products you've recently discovered and tried that you may be concerned is causing an unwanted reaction.
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Do you have any known allergies or sensitivities to fruit, flowers, fragrances, foods, nuts, tree nuts, pollens, or cosmetic ingredients?EVEN IF IT HAPPENED ONE TIME TEN YEARS AGO, SELECT YES.
YESNO
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Please list all known allergies and sensitives here.
Huge
Large
Normal
Small
Ok
Ok
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Do you experience acne?
Yes, all the time.
No, never.
Rarely, stress related
As an Allergic Reaction
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Have you ever used: Please check all that apply:
Azelaic Acids (Azelex)
Differin
Renova
Retin-A/Retina
Renova
Tazorac
Glycolic Acid
Alpha Hydroxy Acid (AHA's)
None of the above
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If yes, please explain your acne experience?Where and how often do you breakout?
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How long did you take the prescription?
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Are you presently taking the prescription?
YESNO
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Have you ever had any type of skin cancer?
Yes
No
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If yes, please list the type of cancer, the area(s) affected and where you are in the course of treatment.
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Do you have any of these medical conditions?
Anxiety
Asthma
Cardiac Problems
Diabetes
Eczema
Epilepsy
Chronic Headaches
Depression
High Blood Pressure
Hepatitis
Lupus
Metal Bones, Pins, or Plates
Herpes
Hysterectomy
Immune Disorder
Kidney/Renal Failure Liver Failure
Pacemaker
Psychological Problem
Sinus Problems
Skin Diseases
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Are you presently taking any medications?Many medications have a direct effect on the skin.
YESNO
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Please list ALLKnowing this information will allow me to identify the cause of certain skin conditions and create the proper treatment plan.
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I would like to know all about my skin condition and how to care for it!
True
False
Unsure
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I like to be presented with options for my skin type, condition, and issues!
True
False
Unsure
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I'd prefer to purchase products that offer results no matter the cost.
True
False
Unsure
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Price is important, but the result of healthier skin is worth the investment.
True
False
Unsure
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I don't understand medical terms and don't care to; just make me beautiful.
True
False
Unsure
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I want a personalized skin care regimen and plan tailored to my skincare needs.
True
False
Unsure
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I love products that smell fragrant and have an attractive appearance and or color.
True
False
Unsure
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My favorite natural fragrance is:Flower, tree, plant, fruit, berry, wood, spice.
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I get itchy when I use products with fragrances or dyes.
True
False
Unsure
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I pile on the make-up to hide acne scars.
True
False
Unsure
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I am willing to do the daily maintenance to achieve my skincare goals.3-5 Steps 2 Times Per Day
True
False
Unsure
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I like products that are:
Lightweight
Thick
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I need help learning what make-up is appropriate for my skin type.
True
False
Unsure
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Welcome to the beginning of your skin optimization journey!

At Victorious Esthetics, we optimize your skin, helping you achieve your skin health goals by customizing your skin health diet based on your skin type, condition, and goal using natural ingredients and plant alchemy!

We've been researching, creating, and testing customized formulas for live human beings since 2013, with success stories from customers who took a chance on natural remedies and have happily achieved their skincare goals ever since!

This is the beginning of our process and the first step of entry into one of our exclusive Victorious Beauty Health Clubs:

Acne-Fighters

Clarity Seeker

Graceful Agers

Natural Desires Hair Growth Challenge

Sensitivity Soothers

By completing this consultation form, your concerns, goals, and desires can be addressed in your Skin Health Consultation and Professional Analysis.

We can then enroll you in your Skin Health Club and get you started on the path of Skin Optimization!

Please complete the following statements so that I can better understand the state of your skin and its relationship to your endocrine and reproductive systems.

Please complete as many as you can in reverse chronological order so that I may understand the evolution of your skin.

Do not complete the sentence if you've not yet experienced something on the list.