New Client Consultation Form

CLIENT CONSULTATION FORM
How did you hear about Skin by Naz?*
If a friend referred you, please share their name
Please fill out this form ONLY if you already have an appointment scheduled or plan to do so within the next few days. Thank you!
Name*
Date of Birth*

MonthDayYear
Age*
Email Address*
Phone Number*
What is your preferred method of contact?*

EmailTextPhone
Mailing Address*
City, State, Zip*
What do you want to accomplish by working together?*

Control acne breakouts and improve scarringKeep your skin looking youthful so you age more gracefullyBalance your skincare routine to clean up your bathroom counterGive your skin back it's glowImprove your skin discolorationWork together to calm and balance sensitive skinJust relax, not concerned with education and/or skincare product options
How often do you receive professional skin treatments?

MonthlyQuarterlyRarelyNever
How would you describe your skin?

OilyDryNormalCombination
What you do not like about your SKIN?*
Out of your skincare goals, what is MOST IMPORTANT to you right now?*
Do you have any of the following?

Skin TagsCherry AngiomasSebaceous HyperplasiaMiliaBroken Vessels (Face Only)Seborrheic Keratoses
What is your occupation?
What are some things you like to do in your spare time?
Does stress affect your sleep?

YesNoSometimes
What do you do to manage stress? Examples: meditation, yoga, exercise, etc.
How much water do you consume daily?

Very Little to None50-70% of Body Weight
Do you have any digestive concerns?

BloatingExcess GasConstipationAcid RefluxFood Sensitivities
Do you follow a special diet?

VeganVegetarianKetoGluten FreeGluten + Dairy FreeDairy FreeOther Not Listed
ACNE CLIENTS, give an example of your daily food intake: breakfast, lunch, dinner, and snacks
Do you have a history of yeast or urinary tract infections?

YesNo
Please list any medical conditions
Do you have a pacemaker or a seizure disorder?*

YesNo
Do you have allergies to:*

AspirinFragranceFruitsMilkOtherTree NutsNone
If your allergy is not listed, please list here:
Please explain what happens when you are exposed to what you are allergic to if applicable.
What medications are you currently taking?*
What supplements are you currently taking?*
Do you have a history of cold sores?*

YesNo
Please note: If you are prone to cold sores and experiencing a breakout, you will not be able to receive any facial or waxing service until you are completely healed.
Do you smoke or use a vape pen?*

YesNoPrevious smokerSometimes
Do you consume alcoholic beverages?*

YesNoSometimes
Have you had Botox or cosmetic fillers within the past 30 days?*

YesNo
Are you currently undergoing Cancer treatment?

YesNo
Are you a Cancer survivor?

YesN/A
Please add any additional information pertaining to Cancer if applicable
Are you pregnant or trying to become pregnant?*

YesNoN/A
If pregnant, when are you due?
Do you have hormone related pigmentation such as Melasma?

YesNoUnsure
Have you been diagnosed with Rosacea?

YesNoUnsure
Do you suffer from Acne?

YesNoOccasional breakouts
Are you currently being seen by a physician for Acne?

YesNoI have in the past
Have you ever used Accutane?

YesNoUnsure
If you were on Accutane, when did you discontinue treatment?
How dedicated to your at home skincare routine are you?*

Very dedicatedSomewhat dedicatedIt's not that important to me
Where do you typically purchase your at home skincare products?*
What skincare products are you currently using in the MORNING?*
What skincare products are you currently using in the EVENING?*
Are there skincare products you are currently using that you love? Which ones and why?
Have you ever had a reaction to skincare products? If so, please explain:
I acknowledge that with any optional skin treatment certain risks are involved and that complications from known or unknown causes could occur. If I am receiving optional skin treatments at Skin by Naz and I experience any unusual side effects, I will contact Naz Panjwani immediately.

I understand that if I purchase a package of treatments or skincare products, individual results vary and I will not be given a monetary refund if I am unsatisfied. I will be offered a credit to use toward other services or products within a reasonable amount of time if proper notification is given.
Please read the policies about Skin by Naz at our website which covers services and product purchase and by signing at the bottom confirms you agree with the business policy.

We require 48 hour cancellation notice for all services. Rescheduling or canceling after the required cancellation window will result in a 50% charge of total service. Anyone who forgets or chooses to forgo their scheduled appointment without any notice will be charged the full value of the scheduled treatment.

APPOINTMENT CHANGES OR CANCELLATION PLEASE TEXT ME

817-703-9902 and I wil handle it for you
The information I have provided is accurate to the best of my knowledge and I understand the 48 Hour Cancellation Policy*
Please Initial
Emergency Contact*
Relationship*
Emergency Contact Phone Number*
Should be Empty:

CLIENT CONSULTATION FORM