Virtual Skin Consulting Intake Form | The Barbertician Beauty & Grooming Co

Virtual Skin Consultation | Intake Form

Client Info

Full Name

Preferred Name

Email

Phone

Date of Birth

State of Residence

Emergency Contact Name

Emergency Contact Phone

Your Main Skin Concerns

What is your primary skin concerns?

Please describe your main skin concerns in your own words.

How long have you been dealing with this concern?

How has this concern been changing over time?

Getting better

Getting worse

Staying the same

Comes and goes

Your Skincare Goals

What are your top skin care goals right now?

Ex., clearer skin, fewer ingrowns, less dryness, brighter skin, smoother texture, more even skin tone.

Skin Type and Symptoms

Current Routine

What skincare products do you use in the morning?

Include cleanser, toner, serums, moisturizer, sunscreen, beard products, or anything else you use.

What skincare products do you currently use at night?

How consistent are you with your routine?

Very Consistent

Somewhat consistent

Inconsistent

I do not currently have a routine

Product and Treatment History

Please list any recent facials, peels or professional skin treatments.

Allergies, Sensitivities, and Relevant Health Information

Known allergies or sensitivities

Are you currently using any prescription medications or topical prescriptions that may affect your skin?

Yes

No

If yes, please explain

Are you pregnant or breastfeeding?

Yes

No

Prefer not to answer

Beard Area Questions

Is your concern related to the beard area?

Yes

No

Please describe your beard-area concern

Red Flag Screening

Are you currently experiencing severe swelling, open wounds, infection, fever, or rapidly worsening symptoms?

Yes

No

If yes, please seek medical care rather than continue with the consult.

Photo Uploads

Please upload clear, makeup-free, well-lit photos. Natural lighting is preferred when possible. Avoid filters.

Front Facing photo

Left-side photo

Right-side photo

Close-up of main concern area

Additional photos (i.e., beard area close-up, under chin area

Consent and Acknowledgement

Please review and confirm each statement below before submitting your consultation form.

Consent Confirmation

I understand this service provides virtual esthetic and skincare guidance only.

I understand this consultation is not medical diagnosis or treatment.

I understand recommendations are based on the photos and information I provide.

I understand unclear photos or incomplete information may limit recommendations.

I understand I may be referred to a medical provider if my concern appears outside esthetic scope.

I understand no specific results are guaranteed.

I consent to submit photos and skincare information for consultation purposes.

I agree to the consultation policies and service-related communication.

Communication Preferences

Service Communication Consent

I agree to receive email and/or text communication related to my consultation, recommendations, and follow-up.

Marketing Updates

I would like to receive promotions, service updates, and product announcements.

Optional Testimonial and Photo Release

This section is optional and is not required to receive service.

May we use your testimonial or written feedback for marketing?

Yes

No

May we use your submitted photos for educational or marketing purposes?

Yes

No

If yes, how would you like to be identified?

Full name

First name only

Anonymous

Electronic Signature

Type your full name as your electronic signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Date

Month

Day

Year

By typing your name above, you confirm that the information you provided is accurate and that you agree to the terms of this virtual consultation.