Consultation & Consent

Virtual Consultation & Consent

Welcome to the Face To Face Esthetics virtual consultation ... if you're ready to begin your journey to healthy, beautiful skin you've come to the right place! I'm Teri Kotantoulas and I've been a Licensed Esthetician for more than twelve years, licensed in both California and Colorado. With the information you provide here, I'll work to create a customized skin care regimen just for you. Please be prepared to upload three selfies (your "before" pictures); you may want to take your selfies before starting this questionnaire. It'll probably take 15 minutes to complete this initial consultation. After you've made your payment, you'll receive either some follow-up questions or your customized skin care regimen. If you decide to purchase the full recommended skincare regimen the $50 consultation fee will be applied to your purchase.
Date:

Month Day Year
Name: *

First Name Last Name

Address: *

Street Address

City	State
Zip Code	Country

Phone Number: *

Area Code Phone Number
Email: *
example@example.com
Birthdate *

Month Day Year
Date
How would you prefer to be contacted to continue this consultation?

Email Phone Call Text Message

WRAP UP & CONSENT
How did you hear about Face To Face Esthetics?

Web Search Referral Advertisement Facebook Camarillo Chamber of Commerce
Say Cheese! It's time to upload three selfies ... one front face photo, one from the right side, and one from the left side. Try to take these photos with good lighting in a place that you'll be able to replicate later. This will make assessing follow-up photos easier.
Front Face Photo *

Browse Files
Upload Cancel of
Right Side Photo *

Browse Files
Upload Cancel of
Left Side Photo

Browse Files
Upload Cancel of
BEFORE / AFTER PHOTOS: Any photos will be kept for reference in your confidential file. Face To Face Esthetics reserves the right to use said photos for marketing purposes. Clients will not be identifiable in any photos used for marketing purposes, and names will not be disclosed. I acknowledge and give Face To Face Esthetics permission to use my photos for any lawful purpose including marketing publicity, illustration, advertising, education, and/or web content. *
Choose one.
I understand that Face To Face Esthetics and staff do not diagnose or treat illness, disease, or any other physical or mental disorder. *
Initial In Box
I understand that results differ from person to person and are not guaranteed. I also understand that compliance with home care recommendations can improve results. *
Initial In Box
By initialing here, you are consenting to the use of your electronic signature in lieu of a signature on paper with pen. You have the right to request a paper/pen signature; by initialing here you are waiving that right. After consent and upon written request, you may obtain a paper copy of this electronic record. Your agreement to use an electronic signature with us for any documents will continue until such time that you provide us written notification that you no longer wish to use an electronic signature. There is no penalty for withdrawing consent. Please make sure we have your current email so we may contact you regarding any changes, if necessary. *
Initial In Box
CLIENT WAIVER & RELEASE: I understand, have read and completed this questionnaire truthfully and to the best of my knowledge. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications to product recommendations. Using any recommended products are voluntary, and I release the esthetician, institution, and/or staff from liability and assume full responsibility thereof. *
Please Sign Here

Virtual Consultation Fee

Virtual Consultation Fee $ 50.00

Virtual Consultation Fee

Total $ 0.00

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Date	Postal Code

THANK YOU! Once your payment has been confirmed, you will receive an evaluation based on your answers as well as any follow-up questions that may be necessary. From there, you will receive a personalized regimen recommendation which can be purchased and mailed right to your doorstep.!
Face To Face Esthetics

1000 Paseo Camarillo, Suite 136, Camarillo, CA 93010

805.669.7743 | FaceToFaceEsthetics.com
Should be Empty:

Now create your own JotForm - It's free! Create your own JotForm

Virtual Consultation & Consent