VIRTUAL CONSULT

No time to schedule an in-person consultation? Not really sure where what you should be scheduling? We totally get it and want to make this process as easy as possible! Kick off your skincare journey from the comfort of your own home. Simply fill out the information below and upload your photos and our Concierge team will be in touch to discuss next steps!

A Consultation Doesn’t have to be scary
You can kick off your skincare journey from the comfort of your own home!

Step 1 of 3

Fill our form

Name*
Full Address*
Date of Birth*
How did you hear about us?
Why are you contacting us Today? How can we help you?*

Step 2 of 3

HIPPA & Telehealth Consent:

Why are you contacting us Today? How can we help you?*

The Vanity Bar Virtual Assessment HIPPA & Telehealth Consent: 
I hereby consent that The Vanity Bar may review the information and photos I am submitting using their Virtual Assessment tool. 
I understand that my Provider has elected to utilize telehealth and online communication services to conduct virtual examinations and manage my care plan.  This may include 1) electronic consents and questionnaires delivered to my secure Patient Portal and required to be completed prior to my appointment 2) email communications regarding my appointment and login information, and 4) participating in my exam via two-way, live-streamed, video consultations for new and existing patients via a HIPAA-compliant portal.
I hereby consent to communicate by cell, e-mail, and online with my Provider so as to arrange and conduct virtual consultations, telemedicine/telehealth, and any other purposes deemed by my provider to be appropriate while I am receiving medical and aesthetic services.
As announced by the US Department of Health & Human Services (“HHS”) on March 17, 2020, I understand my Provider is now authorized to use non-public facing audio and/or video communication technology to provide telehealth, whether or not related to COVID-19, on an acceptable non-public facing platform.  I accept that even authorized non-public facing third-party applications potentially introduce privacy risks, but my provider will enable all available encryption and privacy modes when using these applications.
I understand that I have the right to revoke this authorization in writing at any time, but if I do so it will have no effect on any actions taken prior to my revocation.  Unless and until I revoke this authorization, it will exist in perpetuity from the date written below.  I understand that I may refuse to sign this authorization and such refusal will have no effect on the medical treatment I receive from my Provider.

I release and discharge my Provider, the telehealth software portal and all parties acting under my Provider's license and authority from any telehealth medical privacy claims I might otherwise have had prior to HHS’s March 17, 2020 notification.  I certify that I have read this Authorization and Release and fully understand its terms.

Signature*
Date* (mm/dd/yyyy)

Step 3 of 3

Upload your photos

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Left side.
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YAY!
Thank you for submitting your Virtual Consult information. Our Concierge team will contact you within two business days to discuss next steps. If you have any questions, please don’t hesitate to contact our team.
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