Confidential Virtual Skin Consultation Form Put your best face forward! Name * First Name Last Name Email * Phone * (###) ### #### Date of Birth Are you a smoker? Yes No Please list all allergies Please list all medications you are taking Are you prone to cold sores? Yes No Select your current level of stress Low level Normal level Moderate level High level Are you pregnant? Yes No How many ounces of water do you drink daily? Do you take vitamin or other supplements? Yes No Do you exercise? Yes No When you go out into the sun you: Always burn (I) Usually burn (II) Sometimes burn (III) Rarely burn (IV) Very rarely burn (V) Never burn (VI) When was your last sunburn? Do you use tanning beds? Have you been under the treatment plan of a: Dermatologist Plastic Surgeon (cosmetic surgery) Esthetician If yes, what procedure? What is your skin type? Normal Dry/Dehydrated Oily Acne/Acne Prone Rosacea How do you feel about the overall quality of your skin? It needs improvement It looks great, I would like to maintain Which skin conditions are you concerned about? Sun spots Skin laxity Dry/rough Please select the areas you would like to work on: Reduction of fine lines Reduction of brown spots/sun damage Acne scars diminished Reduction of redness Reduction of oil/acne Thank you!
