New Client Consultation Form

Customer #
New Client Consultation Form
Today*

DayMonthYear
DateHourMinutesAM/PM Option
Name*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Address*

Street Address

Street Address Line 2

SuburbState

Post Code
Mobile*
Work Phone
E-mail*

Confirmation Email
How did you hear about us?*

Website / Online SearchFacebookInstagramReferralOther
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/videosOnly for clinic and client referenceYou may use photos/videos displaying areas only for social media and marketingYou may use photos/videos for social media and marketing
Your Skin
What are your skin care challenges?*

Wrinkles / Fine LinesHyperpigmentation / Sun DamageAcne / Acne ScarringRedness / RosaceaAgingMelasmaSensitivityOther
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?*

YesNo
If Yes, when?
What Skin Care Products do you currently use?*

Cleanser / Face WashBar SoapFace Scrub / ExfoliantsTonerSerumsMoisturizerSunscreenEye Product(s)Lip Product(s)MaskTreatmentOther
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 usingYes, but not within the last 30 daysYes, but not within the last 6 monthsNoNot sure
If you answered yes to the above, please specify what brand/type
Have you ever received chemical peels?*

Yes, within the last 12 monthsNo
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 monthsYes, within the last 2-3 monthsNo
If yes, please Stipulate what was being treated, frequency and results.
Have you received any of these services in the last 30 days?*

Dermal FillersThreadsAnti-Wrinkle InjectionsLaserSkin TreatmentsDermaplaning/DermabladingNoneOther
If yes, please specify
Your Health
Have you experienced any of these health conditions in the past or present?*

Hormone ImbalanceCancer / Systemic DiseaseHigh Blood PressureDiabetesHeart problemArthritisAuto-Immune DisordersAsthmaEpilepsy / Seizure DisorderFever BlistersHerpesFrequent Cold SoresHIV/AIDSLupusDepression/AnxietyHepatitisHeadaches / MigrainesOtherNone
If you checked yes to any of these please provide further information
Do you take any of the following dietary / health supplements or protein powders?

MultivitaminVitamin CVitamin D/D3ZincOmega 3 / Fish OilB Complex / B12GarlicCalciumFolic AcidMelatoninCoenzyme Q10BiotinCollagen PowderProtein PowderOther
Any known allergies?*

AspirinTree NutsLatexDairyFruitsVegetablesShellfishIodineFragrances / Essential OilsNoneEggsOther
Have you used or been prescribed any medications (topical or oral) for acne / acne control?*

YesNo
If yes, please specify what and date last used
Are you a smoker? *

YesNoSocial
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)*

YesNo
Have you ever experienced claustrophobia? *

YesNo
Please rate your stress level*

LowMediumHigh
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? *

YesNoN/A
If yes, please specify
Are you pregnant or trying to become pregnant?*

YesNoRecently had a baby and am breastfeedingN/A
Any menopause issues? *

YesNoN/A
If yes, please specify
Are you undergoing any hormone replacement therapy?

YesNo
If yes, please specify
MALE CLIENTS ONLY
What is your current shaving system?

Razor / Wet shaveElectricN/A
Do you experience irritation from shaving?

YesNoN/A
Cancellation Policy*

I understand the reservation and cancellation policies at DMK Skin Revision and understand if I fail to give 48 hour notice for appointments that I will be asked for a deposit/my deposit will be forfeited. Please visit https://www.dmkskinrevisionclinic.com.au/terms-and-conditions and ensure you are aware of our terms & conditions before proceeding to submit
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:

New Client Consultation Form

Your Skin

Your Health