VIRTUAL ASSESSMENT FORM

Date *

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DD

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Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

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Phone *

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Date of Birth *

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YYYY

Please check box below, if a message can be left. at this number.

Voicemail

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What services are you interested in. *

Please check all that apply.

Laser hair removal

IPL -Intense Pulsed Light | Skin rejuvenation

Microneedling

Body contouring | Skin tightening

Hydrafacial

Jessner medical grade peel

Eyelash extensions

Other

VIRTUAL CONSENT *

Just like online shopping or email, using Virtual Assessments may subject you to possible privacy or security risk that your health information may be intercepted or unintentionally disclosed. We want to make sure you understand this before we proceed. In order to improve privacy and confidentiality, you should also take steps to participate in this virtual care encounter in a private setting and should not use an employer’s or someone else’s computer/device as they may be able to access your information. You should also understand that this virtual assessment will allow Studio Skin to create a treatment plan for discussion, and that this is not a substitute for the initial physical consultation that will be facilitated by the Technician at the time of your scheduled appointment.

I Understand The Following Information

I have read the following information, and give my consent to this visit being done either by phone call, Zoom, Facetime or email. *

I Understand and I Consent