Client Facial Consultation Form

Client Consultation Form
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Month and day of birth:*
For promotional purposes
Referred By:*
Client, Google, Facebook, Instagram
Occupation: *
These environments tell us about your skin
Check all that apply, have you ever had any of the following conditions:

Allergy/hay feverAnemiaArthritis/rheumatismAsthmaBack problemsBleeding problemsBlood diseaseBlood transfusionCancerChemotherapyDiabetesDizziness/faintingDrugs/alcoholismEpilepsyEye injuryheadachesHeart diseaseHepatitisHerpesHIVLupusMelanomaMigrainesRadiation TreatmentRespiratory problemsSinus ProblemsThyroid ProblemsOther
How would YOU best describe your skin Condition?*

DryOilyNormalCombinationAcne proneSensitiveSun DamageTexturedOther
If Sensitive please describe
Which best describes your skin type?*

Creamy complexion Always burns easily, never tansLight Complexion Always burns, tans slightlyLight/Matte Complexion Burns moderately, tans graduallyMatte Complexion Seldom burns, always tans wellBrown Complexion Rarely burns, deep tanDark Brown Complexion Rarely burns, deeply pigmented
Have you ever had or are you currently taking:

Retin-A Renova, any retinoic acidAccutanePrescription acne medicationBirth ControlCold Sore within the last 6 weeks
When was your last facial?*
Within the last year have you been under the care of a Dermatologist?*

YesNo
If yes please explain:
List any medications (oral & topical), ALL supplements, Vitamins, Greens, diuretics, etc., that you take regularly:*
Do you smoke?*

YesNo
Do you have an allergy to latex, shellfish, iodine, aspirin?*

YesNo
Do you sunbathe or use tanning beds?*

YesNo
How many glasses of water do you drink daily?*
Are you pregnant?*

YesNo
What are your specific concerns/challenges with your skin?*

premature agingSun DamageAcne/blemish ControlStress Reduction/Relaxation BenefitsPigmentation ColorationPore SizeSurface ConditionOther
What skin care products are you currently using on your face?*

SoapCleanserTonerMoisturizerSerumsExfoilantsMasksEye ProductsSPF(Daily)SPF (sometimes)Other
Please list the Brands of each product that you checked off*
Have you ever had chemical peels, microdermabrasion, or any resurfacing treatments in the last 6 months?*

YesNo
Do you ever experience these conditions on your skin?*

FlakinessTightnessObvious DrynessStinging when certain products are usedOther
I understand that Ashley Lynn Esthetics only accepts cash/Venmo as a form of payment for services and products.

I understand that my Credit Card was kept on file for Cancellation and no show purposes when booking my appointment that is why I filled in that information and did not actually pay for my service.

I understand that if I am a no show or if I do not give the proper 48 hour notice of canceling for ANY reason that my card will be charged the cancellation fee.(complete policies are listed on the website at ashleylynnesthetics.com)

I understand that there is NO ATM located at Ashley Lynn Esthetics. I understand that if I ever need a total before my service because I will need products as well I can reach out to Ashley and she can give me a total on anything that I need ahead of time so I am prepared.

I understand that all sales are final on products and no refunds will be issued on services rendered as it is impossible to give back time and products.
Signature*
I understand, read and completed the questionnaire truthfully. I understand that withholding ANY information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I understand that this waiver replaces any verbal or written disclosures. The treatments I receive here are voluntary, and I release Ashley Lynn Esthetics and/or esthetician from any liability, and I assure full responsibility thereof. I hereby grant irrevocable consent to and authorize the use of any reproduction by Ashley Lynn Esthetics, all photographs which are taken of me, negative or positive proof which will be hereby attached for any purposes whatsoever, without further compensation to me. All negatives, together with the prints, video or live internet stream shall become and remain the property of Ashley Lynn Esthetics, solely and completely. I understand and release Ashley Spina from any liability if I should fall or hurt myself in any way on her property located at 641 Union Rd. I understand that Ashley Spina is not responsible for lost, stolen or damaged items including my vehicle that is parked on the property.*
Date*

MonthDayYear
Date

Client Consultation Form