Virtual Consultation
Date*
Name*
Date of Birth*
Address*
Phone Type*
Home
Work
Mobile
Phone Number*
Email Address*
Martial Status
Single
Married
Occupation*
Do you work outdoors?*
Yes
No
Referred by?*
What are your skin goals? *
How would you rate your current diet? *
Unhealthy
Moderately healthy
Really healthy
Had any of the follow treatments?*
Massage
Salt Glow
Seaweed Wrap
Moor Mud
Body Scrub
Other
None of the above
If other, please explain
What is your skin type?*
1-extra light/pale
2-Light
3-Light/Tan
4-Tan
5-Dark Tan
6-Light Brown
7-Dark Brown
8-Deep Brown
How easily sunburned?
1-Always burn easily
2-Can burn easily/Slight Tan
3-Moderat burn/Slow tan
4-Seldom burn/Tans well
5-Rarely burn/Deep tan
6-Rarely burn/Deeply pigmented
Any special skin problems?*
Yes
No
If yes, specify
Had any of the following?*
Chemical Peel
Laser
Microderm Abrasion
Not Applicable
If yes to any, date of last treatment
Ever used any of these products?
Retin-A
Renova
Adapalene Hydroxly Acid
Retinol
Vitamin A based products
Not Applicable
If yes, describe your treatments
Were your treatments in the last 3 months?*
Yes
No
If yes, date of last treatment?
Use(d) any acne treatments?*
Yes
No
Select all that apply
Soap
Toner
Mask
Eye Product
Cleanser
Moisturizer (Day)
Exfoliator
Scrubs
Shower Gels
Body Lotions
Sunscreen
Moisturizer/Cream (Night)
Other
Use any makeup products?*
Yes
No
If yes, what kind?
Any skin products currently used?*
Yes
No
What brand(s)?
Ever used a self tanner of any kind?
Yes
No
If so, what type/brand
Which hair removal methods have you used?
Shaving
Waxing
Electrolysis
Plucking
Tweezing
Stringing
Depilatories
None
Any skin health issues historically?*
Breakouts/Acne
Black/White Heads
Excessive Oil/Shine
Rosacea
Broken capillaries
Redness/Ruddiness
Sun/Liver/Brown spot(s)
Uneven skin tone
Sun damage
Wrinkles/Fine lines
Dull/Dry skin
Flaky skin
Dehydrated
Other
Not Applicable
How are you eyes? Check all that apply
Dehydrated
Wrinkles
Puffiness
Dark Circles
Other
Not Applicable
If other, describe please
How are your lips?
Dehydrated
Cracked/Chapped
Other
Not Applicable
Any allergic reactions to the following?
Cosmetics
Medicine
Food
Animals
Sunscreens
Iodine
Pollen
AHAs
Fragrance
Shellfish
Latex
Drugs
Other
Not Applicable
if other, please describe
What SPF do you use for your face?
How often/when?
What SPF do you use on your body?
How frequently and when?
Recent UV exposure that discolored your skin?
Received any of the following treatments?*
Botox
Restylane
Collagen
Not Applicable
If so, when?
Taking any oral contraceptives?
Yes
No
Not Applicable
If yes, what contraceptives?
Any recent changes to your contraceptives?
Yes
No
Not Applicable
If so, what changes, and when?
Are you pregnant, or trying to be?
Yes
No
Not Applicable
Are you lactating?
Yes
No
Not Applicable
Any menopause issues?
Yes
No
Not Applicable
If so, what issues are you having?
Any hormone replacement therapy?
Yes
No
Not Applicable
If so, please specify
Any irritation from shaving?
Yes
No
Ingrown hairs?
Yes
No
Anything else you want/need us to know?
Is it okay to contact you about future specials?
Yes
No