• New Client Consultation Form

  • Today*
     - -
    2 digit day, 2 digit month, 4 digit year :
  • Date of Birth*
     - -
    2 digit day, 2 digit month, 4 digit year

  • How did you hear about us?*
  • For reference we may want to take photos/videos. Please select the following*

  • Your Skin

  • What are your skin care challenges?*

  • Have you ever had a facial or skin treatment before?*
  • What Skin Care Products do you currently use?*

  • 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. 

  • Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?*
  • Have you ever received chemical peels?*
  • Have you ever received IPL, Laser resurfacing (fractional or ablative) or micro-needling?*
  • Have you received any of these services in the last 30 days?*

  • Your Health

  • Have you experienced any of these health conditions in the past or present?*
  • Do you take any of the following dietary / health supplements or protein powders?

  • Any known allergies?*

  • Have you used or been prescribed any medications (topical or oral) for acne / acne control?*
  • Are you a smoker? *
  • Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)*
  • Have you ever experienced claustrophobia? *
  • Please rate your stress level*

  • FEMALE CLIENTS

  • Are you taking birth control? *
  • Are you pregnant or trying to become pregnant?*
  • Any menopause issues? *
  • Are you undergoing any hormone replacement therapy?

  • MALE CLIENTS ONLY

  • What is your current shaving system?
  • Do you experience irritation from shaving?
  • Should be Empty: