Confidential Client Intake Form

In order to ensure that your appointment goes smoothly, please take a few moments to fill out the form below. If you have any questions, please feel free to contact me at any time. 

Contact Information

General Information

How would you describe your skin?
How would you describe your skin sun exposure tolerance?

Medical History

Lifestyle Considerations

What is your stress level?

Terms & Conditions

I understand that my data will be strictly confidential. This Clinic does not sell, share, or resell information.

 

I confirm that all information in this form is true and accurate.

 

I confirm that if I hold some important information and complications happened, the clinic will not be liable.

 

I release this clinic and hold harmless against any claims, expenses, damages, and liabilities.

 

I agree and understand the terms and conditions.

Skin Image Upload

Please upload pictures of your skin in a well lighted room with a clean dry face without any products on your skin.

 

Your skin images are best taken by a window with natural light:

 

  1. Avoid flash

  2. One picture from each side of your face.

  3. One picture of your face straight on.

  4. A close-up of any skin issues if there is any.

  5. If available, opt for a macro setting to allow for the closest close-ups

  6. Upload your images by clicking below

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Your Skincare Coach will review your intake thoroughly before your Virtual Skin Assessment, Home Care & Treatment Planning appointment and go over it with you in more detail to determine the best skincare recommendations for your specific skin health and goals.

Thank you! 

Thank you!