New Client Consultation Form

Customer #
New Client Consultation Form
Today *

Day Month Year
Date Hour Minutes AM/PM Option
Name *

First Name Last Name
Date of Birth *

Day Month Year
Date
Address *

Street Address

Street Address Line 2

Suburb

Post Code
Mobile *
Work Phone
E-mail *

Confirmation Email
How did you hear about us? *

Website / Online Search Facebook Instagram Referral Other
If you were referred, please let us know who from
If other, please let us know
For reference we may want to take photos/videos. Please select the following *

No Photos/videos Only for clinic and client reference You may use photos/videos displaying areas only for social media and marketing You may use photos/videos for social media and marketing
Your Skin
What are your skin care challenges? *

Wrinkles / Fine Lines Hyperpigmentation / Sun Damage Acne / Acne Scarring Redness / Rosacea Aging Melasma Sensitivity
Please feel free to go into more detail
How long has this been bothering you? *
How would you like to see your skin looking?
Are there areas on your body that concern you? If yes, please specify.
Have you ever had a facial or skin treatment before? *

Yes No
If Yes, when?
What Skin Care Products do you currently use? *

Cleanser / Face Wash Bar Soap Face Scrub / Exfoliants Toner Serums Moisturizer Sunscreen Eye Product(s) Lip Product(s) Mask Treatment
Please detail the SPECIFIC products (BRAND & PRODUCT TYPE/NAME) you are currently using so we can best answer any questions on ingredients and help you meet your skin goals.
Cleanser / Face Wash
Soap
Face Scrub / Exfoliants
Toner
Serums
Moisturiser(s)
Sunscreen
Eye Product(s)
Lip Product(s)
Masks or Treatment
Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives? *

Yes, currently using Yes, but not within the last 30 days Yes, but not within the last 6 months No Not sure
Please specify which product or type, if you answered 'Yes, currently using' to above
Have you ever received chemical peels? *

Yes, within the last 12 months No
If yes, please list the brand/type of peel and result
Have you ever received IPL, Laser resurfacing (fractional or ablative) or micro-needling? *

Yes, within the last 12-18 months Yes, within the last 2-3 months No
If yes, please Stipulate what was being treated, frequency and results.
Have you received any of these services in the last 30 days? *

Dermal Fillers Threads Anti-Wrinkle Injections Laser Skin Treatments Dermaplaning/Dermablading None
If yes, please specify
Your Health
Have you experienced any of these health conditions in the past or present? *

Hormone Imbalance Cancer / Systemic Disease High Blood Pressure Diabetes Heart problem Arthritis Auto-Immune Disorders Asthma Epilepsy / Seizure Disorder Fever Blisters Herpes Frequent Cold Sores HIV/AIDS Lupus Depression/Anxiety Hepatitis Headaches / Migraines Other None
If you checked yes to any of these please provide further information. If not mark N/A *
Do you take any of the following dietary / health supplements or protein powders?

Multivitamin Vitamin C Vitamin D/D3 Zinc Omega 3 / Fish Oil B Complex / B12 Garlic Calcium Folic Acid Melatonin Coenzyme Q10 Biotin Collagen Powder Protein Powder
Any known allergies? *

Aspirin Tree Nuts Latex Dairy Fruits Vegetables Shellfish Iodine Fragrances / Essential Oils None Eggs
Have you used or been prescribed any medications (topical or oral) for acne / acne control? *

Yes No
If yes, please specify what and date last used
Are you a smoker? *

Yes No Social
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks) *

Yes No
Have you ever experienced claustrophobia? *

Yes No
Please rate your stress level *

Low Medium High
Do you exercise? If so what type? *
How well do you sleep and how many hours would you get a night? *
Please let me know if you would like to discuss gut health
Please provide your doctor/physician's name and contact number
FEMALE CLIENTS
Are you taking birth control? *

Yes No N/A
If yes, please specify
Are you pregnant or trying to become pregnant? *

Yes No Recently had a baby and am breastfeeding N/A
Any menopause issues? *

Yes No N/A
If yes, please specify
Are you undergoing any hormone replacement therapy?

Yes No
If yes, please specify
MALE CLIENTS ONLY
What is your current shaving system?

Razor / Wet shave Electric N/A
Do you experience irritation from shaving?

Yes No N/A
I have read the post care instructions and agree to adhere to them *

Yes
Cancellation Policy *

I understand the reservation and cancellation policies at Skin Revision and understand if I fail to give 24 hour notice for appointments that I will be asked for a deposit/my deposit will be forfeited
I have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this skin care professional from liability and assume full responsibility thereof. *

Yes
Signature *

Clear
Should be Empty:

Now create your own JotForm - It's free! Create your own JotForm

New Client Consultation Form

Your Skin

Your Health