Consultation Form
Please fill out information below before arriving to your appointment. Mainly for facial and waxing clients.
Date
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Month
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Day
Year
Date
Name
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First Name
Last Name
Phone Number
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Area Code
Phone Number
Age?
12-17
18-21
22-29
30+
Have you used any skin acne products/topicals such as, Retin-A, Tretinoin, or Accutane in the past 3-6 months?
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Are you allergic to any of the following: (can select multiple if needed)
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Aspirin
Any Dairy
Vitamin A(retinol) or C
Sunscreen
Sulfur
None of the above
Any other allergens? (any other foods, medications, products, etc) If NO, type “NO”
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Have you ever had a reaction to a skin product? If NO type “NO”
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What’s your skin type?
Dry (dry patches, flakiness, tight skin)
Oily (excessive oil, blackheads, enlarged pores)
Combo (tzone area, hormonal breakouts)
Normal (smooth texture, fine pores)
Acne Prone (painful cystic, nodules, etc)
Not sure
Do you use any skincare products at home, if so, what do you use and what brands? (Cleanser, serums, moisturizer, spf) If NONE, type NONE
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Are you interested in skincare products? YES OR NO?
What are your skin concerns and skin goals? (Acne, age spots, hyperpigmentation, anti-aging, etc. If none, type none)
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Do you consume any of these foods?
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Dairy (milk, cheese, ice cream, etc)
Whey protein
Peanut butter
Biotin or B12 vitamins
Seafood
None of the above
If you consume any of the following foods, how much do you eat in a week? (Example: Dairy-daily or 3X a week.)
List any taken medications and health issues you currently have. How long? (Birth control, thyroid problem, herpes simplex, eczema, psoriasis, lupus, etc)
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If you’re receiving a chemical peel, do you AGREE to avoid sun exposure for 7-10 days and wear SPF 30+ on face?
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Yes
No
SIGNATURE AGREEMENT (Client/Minor’s Guardian) - I have read and completed the questionnaire truthfully and to the best of my knowledge. I understand that withholding information or providing misinformation MAY lead to irritations and reactions on the skin. These treatments I receive are voluntary and I release PRIMM AESTHETICS from any liability. I consent that the answers provided are the truth and correct. I consent that I have not withheld any information that may be relevant to my treatment(s). I consent to all future services/treatments/appointments!
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Submit
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