Virtual Skincare Consultation Intake Form
Thank you for booking your Virtual Skincare Consultation with J. Lanique Glam Studio! Before we meet, please take a few minutes to complete this intake form thoroughly. Your answers will help me understand your skin type, current routine, lifestyle factors, and skincare goals so I can create a personalized treatment plan tailored just for you. Please be as honest and detailed as possible. This allows me to recommend professional-grade products that truly support your skin’s needs. What You’ll Need: ・5–10 minutes to complete the form. ・Good lighting if you’re uploading photos ・ Information about the skincare products you currently use ・Any known skin sensitivities or allergies Why This Matters: ・Your skin is your largest organ and changes with age, stress, hormones, and routine. ・The more I know, the better I can support your skincare journey. ・My goal is to provide you with a custom plan and product recommendations that get real results. After completing this form, you’ll receive a confirmation email with your consultation details. Please be on time and ready for our video call with clean, makeup-free skin in natural lighting (if possible). Let’s get you glowing—inside and out!
1.) Basic Info:
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Date of Birth
-
Month
-
Day
Year
Date
Preferred Contact Method
Phone
Email
Text
Other
2.) Skin Type (Check all that apply)
Dry
Oily
Combination
Sensitive
Normal
Unsure
3.) Skin Concerns (Check all that apply)
Acne/Breakouts
Blackheads/Whiteheads
Texture
Uneven Skin Tone
Hyperpigmentation
Dark Marks/Acne Scars
Fine Lines/Winkles
Large Pores
Dryness/Flakiness
Oily Skin/Shine
Dullness/Lack Of Glow
Redness/Inflammation
Other
4.) Current Skincare Routine
(List the products you currently use in each step. Leave blank if not applicable.)
Cleanser(s):
Toner(s):
Serum(s):
Moisturizer(s):
SPF:
Treatments (acne, retinol, peels, etc):
Weekly Mask(s)/ Exfoliate(s):
Other:
5.) How often of you exfoliate
Never
1-2x a week
3-4x a week
Daily
6.) Do you wear SPF Daily
Yes
No
Sometimes
7.) Have you ever has a reaction to skincare products?
Yes
No
If yes, please explain:
8.) Medical History
Are you currently pregnant or nursing?
Yes
No
Do you have any allergies? (ingredients, medications, etc.)?
Yes
No
If yes, please list.
Do you have any diagnosed skin conditions (eczema, rosacea, dermatitis, etc.)?
9.) Lifestyle Factors
(These help you assess skin from the inside out.)
Water Intake daily:
Less than 2 cups
2-4 cups
5+ cups
Diet:
High Sugar/Dairy
Balanced
Lots of Processed Food
Vegan/Vegetarian
Other
Stress Level:
Low
Medium
High
Sleep Schedule:
Good
Inconsistent
Poor
Hormonal Changes:
Birth Control
Postpartum
Menopause
Cycle-Related Breakouts
10.) Skin Goals
What are your top 3 skin goals right now?
1.
2.
3.
11.) Preferred Product Range
Please select the type of skincare products you’d like included in your plan. You can change this later after we review your skin needs together.
What is your current skincare budget (per month)?
I prefer professional-grade skincare only (higher performance, long-term results)
I prefer a mix of professional and drugstore options
I prefer affordable/drugstore options only
I’m open to any products that are best for my skin
12.)Upload Photos
Front, Left, and Right Profile (in good lighting)
Front
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Left
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Right
Browse Files
Drag and drop files here
Choose a file
Cancel
of
13.) Preferred Video Chat Platform
Please select the video chat platform you’d like to use for your virtual skincare consultation. A secure link will be sent to you based on your choice prior to your scheduled appointment.
What platform do you prefer
Zoom
Facetime (iPhone iPad users only)
Google Meet
No preference-use what's easiest for you
Virtual Skincare Packages
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Package 1: Virtual Glow Consultation
Perfect if you want expert skincare advice and a fully customized plan using professional-grade products. This package is service-only — products are purchased separately so you can build your perfect routine. Includes: • 30–45 minute virtual consultation • Personalized AM & PM skincare routine • Professional product recommendations with clickable links to purchase • 14-day follow-up support via email or DM Products not included — you’ll receive your recommendations with easy links to order directly.
$
60.00
Package 2: Glow Start Kit + Virtual Consultation — $129 (Products Included)
Jumpstart your skincare journey with expert guidance and a starter product bundle shipped to your door. Includes: • 30–45 minute virtual consultation • Personalized AM & PM skincare routine • Customized Starter Kit (3–4 professional products tailored to your skin type) • Product shipping & delivery included • 14-day follow-up support via email or DM Value: Products + expert guidance = $180+ value for just $129.
$
130.00
VIP Glow-Up Package
VIP Glow-Up Experience — $199 (Full Transformation Kit Included) For clients ready for a complete skincare transformation. This package includes a premium product bundle, ongoing support, and exclusive perks. Includes: • Everything in the Glow Start Kit package • 30-day follow-up check-in (video or phone) • Up to 5 full-size professional products tailored to your skin type & goals • Priority access to future product launches + exclusive discounts • Skincare tracker sheet + digital glow-up guide Value: Products + expert guidance + follow-up care = $300+ value for just $199.
$
200.00
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
Please select the day(s) that work best for your virtual skincare consultation. This helps me match your availability with mine so we can schedule a time that works for both of us.All consultations are done via video call (Zoom, FaceTime, or Google Meet) and last about 30–45 minutes. You’ll receive a confirmation message once your appointment is scheduled.Let me know if you’re flexible or have specific time preferences in the additional notes section at the end of this form.
14.)Additional Notes
(Is there anything else you’d like me to know before your consultation?)
15.)Terms & Conditions
By booking a Virtual Skincare Consultation with J. Lanique Glam Studio, you acknowledge and agree to the following: ・Consultation Purpose:This virtual consultation is intended to provide professional skincare advice and product recommendations based on the information you provide. It is not a substitute for medical advice, diagnosis, or treatment from a licensed healthcare provider or dermatologist. ・Accuracy of Information:You agree to provide honest and accurate information on your skin type, concerns, and medical history. Recommendations are made based on your responses and visible skin analysis during the consultation. ・Results Disclosure: Skincare results vary by individual. No specific outcome can be guaranteed. Consistency, proper use of recommended products, and lifestyle habits play a significant role in skin health. ・Product Purchases: Products recommended may be available for purchase via Skin Script, Pomp, or other professional suppliers. Product purchases are optional but highly encouraged for best results. ・Privacy:All personal and skincare information collected is confidential and used solely for the purpose of your consultation and follow-up.
16.)Cancellation & Rescheduling Policy
・Cancellations must be made at least 24 hours in advance of your scheduled consultation time. ・If you cancel with less than 24 hours’ notice or do not show up for your appointment, the consultation fee is non-refundable and cannot be transferred. ・You may reschedule one time with at least 12 hours’ notice, subject to availability. ・Consultation fees are non-refundable, but if you proceed with product purchases during your consultation, a portion of your consultation fee may be applied as product credit (if applicable at the time of booking
17.)Consent
*
By submitting this form, I acknowledge that the skincare advice and product recommendations given are based on the information I have provided and do not replace medical advice from a dermatologist or healthcare provider. I agree and understand
Client Acknowledgement & Consent By signing below, I confirm that all information provided in this form is accurate and complete to the best of my knowledge. I understand that the recommendations and guidance provided during my virtual skincare consultation are based solely on the information I have provided and a visual analysis via video call. I acknowledge and agree to the Terms & Conditions and the Cancellation & Rescheduling Policy outlined by J. Lanique Glam Studio. I understand that this consultation does not replace medical advice from a licensed dermatologist or healthcare provider. I give my full consent to proceed with this virtual skincare consultation.
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