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 *

Month Day Year

Age *

Email Address *

Phone Number *

Address *

Street Address

Street Address Line 2

City State / 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 plan Give your skin back it's glow, improving inner and outer beauty Work 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 Tags Cherry Angiomas Sebaceous Hyperplasia Milia/Clogged Pores Broken Vessels (Face Only) Seborrheic Keratoses

What is your occupation? *

What are some things you like to do in your spare time? *

How often do you receive professional skin treatments? *

Monthly Quarterly Rarely Never

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 Low 2 3 Medium 4 5 High

What do you do to manage stress? Examples: meditation, yoga, exercise, etc.

How much water do you consume daily?

Very Little to None 50-70% of Body Weight

What types of water do you drink most often?

Tap water Filtered water Spring water Alkaline water Distilled water Purified water Artificially flavored water Naturally flavored water

What type of milk do you consume?

Cow's milk Coconut Almond Soy

Do you drink coffee?

Hot Cold Caffeinated Decaffeinated Artificially flavored

How often do you drink coffee? How many cups per day?

Do you consume alcoholic beverages?

Yes No Sometimes

Do you follow a restricted diet?

Vegan Vegetarian Keto Gluten Free Gluten + Dairy Free Dairy Free Paleo

Approximately 80% of the food you consume is:

Do you eat salads?

Yes No

How often do you eat salads?

Do you drink smoothies?

Yes No

How often do you drink smoothies?

Do you eat fresh fruit?

Yes No

How often do you eat fresh fruit?

Which kinds of fresh fruit do you eat?

Do you drink protein shakes or eat protein bars?

Yes No

Are the protein shakes/protein bars:

Vegan based Animal based Vegan + Animal based

Breakfast

Lunch

Dinner

Snacks

Does stress affect your sleep? *

Yes No Sometimes

Do you have allergies to: *

NO KNOWN ALLERGIES Aspirin Fragrance Fruits Milk Tree 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? *

YES No N/A

If pregnant, when are you due?

Are you currently undergoing Cancer treatment?

Yes No

Are you a Cancer survivor? *

Yes N/A

Please add any additional information pertaining to Cancer, if applicable.

Do you have any digestive concerns? *

Constipation more than once per month Diarrhea more than once per month Bloating Gas (upper or lower) Acid reflux Stomachaches History of IBS, Crohns, etc. None

Do you have a history of yeast or urinary tract infections? *

Yes No

Do you have a pacemaker or a seizure disorder? *

Yes No

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?

Yes No Some do Unsure

Do you have a history of cold sores? *

YES No

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? *

Yes No Previous smoker Sometimes

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

YES No

Do you suffer from Acne? *

Yes No Occasional breakouts

Are you currently being seen by a physician for Acne? *

Yes No I have in the past

Have you ever used Accutane? *

Yes No Unsure

If you were on Accutane, when did you discontinue treatment?

How dedicated to your at home skincare routine are you? *

Very dedicated Somewhat dedicated It'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?

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 *

Clear

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