Skincare Client Consultation Form

SKINCARE CLIENT CONSULTATION FORM
How did you hear about Skintuition Holistic Skincare?
If a friend referred you, please share their name
Do you have an appointment scheduled?

Yes, I'm all set!Not yet, please contact me
Do you live in Arizona seasonally?

YesNo, this is my permanent home
Name
Date of Birth (Month/Day/Year)
Age
Email Address
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact
Relationship
Emergency Contact Phone Number
What is something you love about your face and/or skin?
What would you like to achieve together?

Maintain a "healthy aging" approach and look the best for your ageGive your skin back it's glow, improving inner and outer beautyWork to balance common skin concerns such as mild acne, rosacea, dryness, reactive
Are there any other goals you have that aren't listed above?
Do you have any of the following?

Skin TagsCherry AngiomasSebaceous HyperplasiaMilia/Clogged PoresBroken Vessels (Face Only)Seborrheic Keratoses
Lifestyle
What is your occupation?
What are some things you like to do in your spare time?
How often do you receive professional skin treatments?

MonthlyQuarterlyRarelyNever
Do you have allergies to:

NO KNOWN ALLERGIESAspirinFragranceFruitsMilkTree NutsOther
Please explain what happens when you are exposed to what you are allergic to, if applicable.
Are you pregnant or trying to become pregnant?

YESNoN/A
If pregnant, when are you due?
Are you currently undergoing Cancer treatment?

YesNo
Are you a Cancer survivor?

YesN/A
Please add any additional information pertaining to Cancer, if applicable.
Health History
Do you have a pacemaker or a seizure disorder?

YesNo
Please list any medical conditions
What medications are you currently taking and their purpose?
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.
Have you had Botox or cosmetic fillers within the past 30 days?

YESNo
Do you suffer from Acne?

YesNoOccasional breakouts
Your Current Skincare Routine
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?
Do you experience irritation or redness after using any of your current skincare products? If so, which ones?
Policies to Keep Business Running Smoothly
I acknowledge that with any optional personal care service, certain risks are involved and that complications from known or unknown causes could occur. If I am receiving elective spa services and I experience any unusual side effects, I will contact Tracy immediately.

I understand that if I purchase a service or product, 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.

CANCELLATION POLICY

CANCELLATIONS WILL BE ACCEPTED ONLINE 48 HRS PRIOR
TO YOUR SCHEDULED APPOINTMENT.

IF YOU NEED TO CANCEL WITHIN THE 48 HR TIME-FRAME, PLEASE CONTACT TRACY AT (703) 864-7939 AS SOON AS POSSIBLE. YOU WILL BE CHARGED A NON-REFUNDABLE FEE OF $50 FOR NON-EMERGENCY SITUATIONS.
I acknowledge and accept Skintuition Holistic Skincare policies as stated above*

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SKINCARE CLIENT CONSULTATION FORM

Lifestyle

Health History

Your Current Skincare Routine

Policies to Keep Business Running Smoothly