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Quick Skin Consultation Form
Quick Skin Care Questionnaire - SK Esthetics
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* Indicates required question
This form typically takes 4-8 minutes for you to complete and will help give us a better idea of what you are looking to achieve from professional facial services at SK Esthetics
1) Please write your first and last name below
*
Your answer
2) What is your email address
*
Your answer
3) What is your date of birth
*
MM
/
DD
/
YYYY
4) What cell phone number can we contact you on?
Please check it is accurate. This is the number we will use to text and call you on for an initial phone consultation.
*
Your answer
5) How did you hear about SK Esthetics
Please CHECK
*
Google Search
Yelp
I'm a returning customer
Someone recommended me
Other
Required
6) How often do you receive professional facials ?
Please CHECK
*
Weekly
Monthly
Yearly
Very Rarely
Required
7) Are you presently under a physicians care for any current skin condition or problem?
Please CHECK
*
Yes
No
Required
8) If you answered YES to question #7
Please WRITE
the name of your current medically diagnosed skin condition or problem
Your answer
9) Are you presently under a physicians care for any health condition that we should be aware of ? This does not need to be related to skin.
PLEASE CHECK
*
Yes
No
Required
10) If you answered YES to question #9
Please WRITE
below the name/s of the current medically diagnosed health concerns you have, that we should be aware of
Your answer
9)
Please CHECK
below any of the following skin concerns you would like your professional skin care treatments to address.
*
Acne - Mild (present as pimples on the skin, not painful, no scaring)
Acne - Severe (may be sore to touch, inflammation, scarring, cystic)
Rosacea
Dry/ Dehydrated Skin
Aging Skin / Wrinkles
Large Pores
Black or White Heads
Sun or Hormonal Damaged Skin
Hypopigmentation
Hyperpigmentation
I do not know what I have going on, I need your help to tell me
Required
10) If you have an idea of a specific treatment you are looking for
Please WRITE
it below. Our skin care menu on our website skesthetics.com gives a overview of the treatments we provide.
If you do not know, that's totally fine, just skip to question #11
Your answer
An Esthetician is going to call you to have a phone consultation in regards to your specific skin care concerns, goals and needs.
They can call between 9am-6.30pm Mon-Sun and will use the phone number you have provided us in this form.
11) What is the best time to call you for a more in-depth phone consultation between 9am-6.30pm Mon-Sun?
Please CHECK
below
*
Any time between 9am-6.30pm Mon-Sun is fine
I need to be called at a specific time ( If this applies to you, go question #12)
Required
Please WRITE
below your preferred call back times between 9am-6.30pm Monday thru Sunday. Feel free to also indicate to us if you have flexibility in the times and/ or the time of the window you have.
For example
Anytime Monday between 12-2pm
Your answer
Thank you for your information it is confidential and will not be used for anything else other than to determine the suitability of our in office treatments.
If we need more information we will ask during your phone consultation as we may require additional questions to be answered prior to determining your treatment.
We look forward to talking to you soon and scheduling an appointment.
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