Virtual Skin Therapy Intake Form 

Birthday

Do you wear contact lenses?*

Do you wear make-up? *

How often do you wear make-up?*

Do you work outside?*

Do you have any allergies?*

Do you have any skin concerns?*

Have you visited a dermatologist before?*

Do you use Retin A, Renova, Adapalene Hydroxyl Acid or retinol/vitamin a derivative product*

Have you used these products in the last 3 months?*

Have you used acne meds like Accutane?*

Have you experienced Botox, Restylane or collogen injections?*

Are you undergoing any hormone replacement therapy?*

Are you taking any oral contraceptives?*

Are you pregnant or trying to become pregnant?*

Are you lactating?*

Are you experiencing any menopause problems?*

Have you used the hair removal treatments on your face in the past 6 weeks?*

Do you break out in any of the following areas?*

Do you have scars?*

Do you have hyperpigmentation?*

Do you have hypopigmentation?*

Which statement applies to your skin?*

Have you received any of the following treatments on your face and/or neck:*

What skin type do you think you have?*

Would do you describe your skin as sensitive?*

Describe your eye area:

Describe your lip area:

Does your skin feel tight or dry after you cleanse your face?*

How did you hear about us?*

What is your budget or price range for products?*