Virtual Skin Assessment

Name *

First Name

Last Name

Phone

(###)

###

####

What is your skin type? Select all that apply. *

Wash your skin and tone. Do not put any serums or moisturizers on for 2 hours. Let your skin breath.

Tight

Flakey

Itchy

Redness

Oily

Dry

Oily t-zone (cheeks, nose, forehead)

Which skin condition are you experiencing? Select all that apply. *

This will help me to recommend treatments based on concerns and conditions.

Redness

Rosacea

Acne

Bumps

Blackheads

Hyperpigmentation

Dark/puffy circles under eyes

Aging

Allergies

If aging, which are you experiencing? Select all that apply. *

If you selected aging above, what conditions are you experiencing?

Change of texture

Large pores

Decrease in elasticity

Fine lines and wrinkles

Visible capillaries

All of the above