New Client Consultation Form

New Client Consultation Form
Date*

MonthDayYear
Name*

First NameLast Name
Date of Birth*
Gender

FemaleMaleNon BinaryTransFluidDon't wish to answerOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
How did you hear about the Secret Garden Spa?*

ReferralWebsiteGoogleInstagramFacebookYelpOther
If Referral, please list name
Your Skin
How would you describe your skin?*

DryNormalOilyCombinationSensitiveOther
What are your skin care goals? *
When was the last time you went tanning, were sunburnt, or used a tanning bed?*

Within the last 24 hoursWithin the last weekWithin the last monthOther
What are your skin care challenges?*

Wrinkles / Fine LinesAgingHyperpigmentation / Sun DamageAcne / Acne ScarringRedness / RosaceaSensitivityMelasmaDullnessEczema/ PsoriasisOther
Please tell me what skincare brands you are using and how often do you use them?
Cleanser / Face Wash
Bar Soap
Face Scrub / Exfoliants
Toner
Serums
Moisturizer(s)
Sunscreen
Eye Product(s)
Lip Product(s)
Other
Do you/have you used glycolic acid, lactic acid, mandelic acid, salicylic acid, hydroquinone, Retinol, Retin-A, Renova, Differen/Adapalene, Accutane (Isotretinoin), Tretinoin (Retinoic Acid), 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, currently using' to the above question, please expand on what you are using, how often, and if it is a prescription.
Have you received any of these hair removal services in the last 30 days?*

WaxingSugaringThreadingElectrolysis / LaserDepliatory Cream - AKA NarShavingNoneOther
Have you ever had any of these skincare treatments in the past?*

FacialMicrodermabrasionHydrodermabrasionChemical PeelWaxingSugaringThreadingMicroneedlingFibroblast/ Plasma PenLaserPhoto FacialDermaplaningBotox/ FillersPlastic SurgerySemi/ Permanent MakeupNoneOther
Do you have keloids or atopic scars?
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 BlistersHerpesCold SoresHIV/AIDSLupusHepatitisHeadaches / MigrainesPsoriasisEczemaNoneOther
Do you?*

Wear contact lensesHave a pacemakerHave metal implantsHave body piercingsNo, not Applicable
Please list all current medications including aspirin, ibuprofen, blood thinners, etc. you take regularly:*
If other, please list
Any known allergies?*

AspirinLidocaineTree NutsDairyFruitsVegetablesShellfishIodineFragrances / Essential OilsNoneOther
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
Have you ever experienced claustrophobia? *

YesNo
Please rate your stress level*

LowModerateMediumHigh
Are you using hormonal birth control?*

YesNoOther
Are you pregnant or trying to become pregnant?*

YesNoRecently had a baby and am breastfeedingOther
Are you undergoing any hormone replacement therapy?

YesNo
If yes, please specify
Post Facial Care/Waxing/ Sugaring Instructions: Aerobic exercise and/or vigorous physical activity should be avoided for 48 hours. Direct sunlight exposure is to be avoided immediately following the treatment (including any strong UV light exposure and/or tanning beds). If some sun exposure cannot be avoided first apply a broad spectrum sunscreen of SPF 30. Sunscreen (with a minimum SPF 30) should become part of your daily skin care regimen as skin can potentially become more sensitized to the sun as a result of certain treatments. Unless otherwise specified, in the evening following your treatment, cleanse your skin with a mild cleanser and water followed by a non-active moisturizer. Do not apply additional exfoliating ingredients/products the day of your service as over-exfoliation can result in irritation or further sensitivity. Enzyme peels, microdermabrasion treatments, chemical peels or facial waxing/sugaring can result in skin flushing/redness or slight skin flaking or sensitivity for up to 48-72 hours post treatment. DO NOT peel, pick, rub, or scratch your skin at any time, whatsoever. This can potentially cause damage or compromise your results.*

I have read the post care instructions and agree to adhere to them.
Appointments need to be canceled or rescheduled 24 hours prior to the appointment time. Failure to do so may result in being charged for 100% of the services. In the case of a no show, clients will be charged for 100% of the services scheduled. If you have a valid reason as to why you missed your appointment or were unable to cancel in time, please let Kathryn know. It is up to her discretion to decide whether or not to charge you.*

I understand the reservation and cancellation policies at the Secret Garden Spa and consent to my credit card on file being charged if I fail to give 24 hour notice for appointments scheduled.
I understand, 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 the Secret Garden Spa and KTroxel LLC from liability and assume full responsibility thereof.

Yes
Signature*

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New Client Consultation Form

Your Skin

Your Health