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Please complete this form prior to scheduling a WeRest Virtual Skin Therapy Session
Virtual Skin Therapy Intake Form
First name
Last name
Email
Phone
Birthday
Month
Day
Year
Upload a picture of the front of your face
*
Upload File
Upload a picture of the left side of your face
*
Upload File
Upload a picture of the right side of your face
*
Upload File
Do you wear contact lenses?
*
Yes
No
Do you wear make-up?
*
Yes
No
How often do you wear make-up?
*
Everyday
On special occasions
Not at all
Do you work outside?
*
Yes
No
What is your occupation?
*
Do you have any allergies?
*
Yes
No
List your allergies here:
*
If there is something you could change about or improve about your skin, what would it be?
*
Do you have any skin concerns?
*
breakouts/acne
blackheads
whiteheads
excessive oil/shine
rosacea
broken capillaries
redness
sun spots/liver spots/browns spots
uneven skin tone
sun damage
wrinkles
dull/dry skin
flaky skin
dehydration
Other
Do you have any specific skin problems or concerns pertaining to your skin?
*
Have you visited a dermatologist before?
*
Yes
No
Last appointment?
*
Why did you visit the dermatologist?
*
What did you like or dislike about your experience?
*
Do you use Retin A, Renova, Adapalene Hydroxyl Acid or retinol/vitamin a derivative product
*
Yes
No
Have you used these products in the last 3 months?
*
Yes
No
Have you used acne meds like Accutane?
*
Yes
No
Please list which products:
*
When did you last use the skincare medication
*
What do you like or dislike about the product?
*
Have you experienced Botox, Restylane or collogen injections?
*
Yes
No
When did you experience this procedure?
*
Are you undergoing any hormone replacement therapy?
*
Yes
No
Are you taking any oral contraceptives?
*
Yes
No
What are you taking?
*
Are you pregnant or trying to become pregnant?
*
Yes
No
Which trimester are you in?
*
Are you lactating?
*
Yes
No
Are you experiencing any menopause problems?
*
Yes
No
Please list any skincare products that you use:
*
How much water do you drink in a day on average?
*
What is your caffeine intake on average daily?
*
Have you used the hair removal treatments on your face in the past 6 weeks?
*
wet shave
electric shave
wax
electrolysis
plucking/tweezing
threading
depilatories (Nair)
N/A
Other
Do you smoke? How often?
*
Do you drink? How often?
*
Are you taking any medications?Are you taking any antibiotics ?Are you taking any supplements?
*
What is your diet like?
*
What is your stress level like 0 (no stress) to 10 (high stress)?
*
Do you break out in any of the following areas?
*
forehead
nose
ears
jawline
chin
neck
hairline
eyebrow area
cheeks
Other
Do you have scars?
*
Yes
No
Do you have hyperpigmentation?
*
Yes
No
Do you have hypopigmentation?
*
Yes
No
Which statement applies to your skin?
*
Choose one
Have you received any of the following treatments on your face and/or neck:
*
facial
waxing
microdermabrasion
lash tint
brow tint
laser surgery
laser hair removal
chemical peels
vein treatments
N/A
What skin type do you think you have?
*
Choose one
Would do you describe your skin as sensitive?
*
Yes
No
Why do you describe your skin as sensitive?
*
Describe your eye area:
dry/dehydrated
normal
wrinkles
puffy
dark circles
Other
Describe your lip area:
dry/dehydrated
normal
chapped
cracked
Other
Does your skin feel tight or dry after you cleanse your face?
*
Yes
No
How did you hear about us?
*
Choose one
What is your budget or price range for products?
*
Choose one
Submit
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