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 take about 15 minutes to complete this initial consultation. After you've submitted the completed form, you'll receive either some follow-up questions or your customized skin care regimen. I look forward to working with you!
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Name:

First NameLast Name
Address:

Street Address

CityState

Zip Code
Phone Number:

Area CodePhone Number
Email:
example@example.com
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
How would you prefer to be contacted to continue this consultation?

WRAP UP & CONSENT
How did you hear about Face To Face Esthetics?
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 Cancelof
Right Side Photo

Browse Files
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Left Side Photo

Browse Files
Upload Cancelof
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
That's it ... keep an eye out for your recommendations soon!
Face To Face Esthetics

1000 Paseo Camarillo, Suite 136

Camarillo, CA 93012

805.669.7743

FaceToFaceEsthetics.com
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Virtual Consultation & Consent