Skincare Client Consultation Form

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

Yes, I'm all set!Not yet, please have someone contact me
Name*
Date of Birth*

MonthDayYear
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?*

Create a "healthy aging" customized skincare planGive 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
On average, how many hours of sleep do you get?
If you routinely wake up in the middle of the night, what time?
Rate your average daily stress level*

1 Low23 Medium45 High
What do you do to manage stress? Examples: meditation, yoga, exercise, etc.
Food and Drinks
How much water do you consume daily?

Very Little to None50-70% of Body Weight
What types of water do you drink most often?

Tap waterFiltered waterSpring waterAlkaline waterDistilled waterPurified waterArtificially flavored waterNaturally flavored water
What type of milk do you consume?

Cow's milkCoconutAlmondSoy
Do you drink coffee?

HotColdCaffeinatedDecaffeinatedArtificially flavored
How often do you drink coffee? How many cups per day?
Do you consume alcoholic beverages?

YesNoSometimes
Do you follow a restricted diet?

VeganVegetarianKetoGluten FreeGluten + Dairy FreeDairy FreePaleo
Approximately 80% of the food you consume is:
Do you eat salads?

YesNo
How often do you eat salads?
Do you drink smoothies?

YesNo
How often do you drink smoothies?
Do you eat fresh fruit?

YesNo
How often do you eat fresh fruit?
Which kinds of fresh fruit do you eat?
Do you drink protein shakes or eat protein bars?

YesNo
Are the protein shakes/protein bars:

Vegan basedAnimal basedVegan + Animal based
Examples of Typical Meals
Breakfast
Lunch
Dinner
Snacks
Does stress affect your sleep?*

YesNoSometimes
Do you have allergies to:*

NO KNOWN ALLERGIESAspirinFragranceFruitsMilkTree Nuts
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 any digestive concerns?*

Constipation more than once per monthDiarrhea more than once per monthBloatingGas (upper or lower)Acid refluxStomachachesHistory of IBS, Crohns, etc.None
Do you have a history of yeast or urinary tract infections?*

YesNo
Do you have a pacemaker or a seizure disorder?*

YesNo
Please list any medical conditions
What medications are you currently taking and their purpose?*
What supplements are you currently taking and their purpose?*
Do any of your supplements contain any silica / cellulose / yeast / sugar / fillers / binders / color / artificial ingredients?

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

YESNo
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?
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
CANCELLATION POLICY

CANCELLATIONS WILL BE ACCEPTED ONLINE 72 HRS PRIOR TO YOUR SCHEDULED APPOINTMENT.

IF YOU NEED TO CANCEL WITHIN THE 72 HR TIME-FRAME, YOU WILL NEED TO CONTACT US AT (703) 653-0567 IMMEDIATELY SO WE CAN CANCEL YOUR APPOINTMENT AND YOU WILL BE CHARGED A NON-REFUNDABLE FEE OF $75 PER SCHEDULED SERVICE.

SAME DAY CANCELLATIONS AND NO SHOWS WILL BE CHARGED THE FULL AMOUNT OF SCHEDULED SERVICES.

DEPOSIT | NEW CLIENTS Healthy Aging Consult + Facial

New Client Facial Deposit$50.00

If you are scheduled for a NEW CLIENTS | Healthy Aging Consult + Facial, we require a NON-REFUNDABLE, $50 DEPOSIT to be paid within 24 hrs to secure your appointment. Your deposit will be deducted at checkout after your service.

Total $0.00

Credit Card

I acknowledge and accept Skintuition Holistic Skincare policies as stated above*

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SKINCARE CLIENT CONSULTATION FORM

Lifestyle

Food and Drinks

Examples of Typical Meals

Health History

Your Current Skincare Routine

Policies to Keep Business Running Smoothly

Credit Card