Skincare Services Consultation Card

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Name* This field is required.
First Name
Last Name
2
PronounsEx. She, He, They
3
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Email* This field is required.
example@example.com
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Phone for future communication* This field is required.A phone number you'd like us to use for follow up communication
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Birth Date
Month
Day
Year
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Age Range* This field is required.
under 21
21-30
31- 40
41– 50
51- 60
60 +
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Any Social Media to share?
Twitter, Facebook, Instagram, Youtube, etc.
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How did you hear about us?* This field is required.
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Occupation* This field is required.
11
Do you work around chemicals, tars, oils, grease or inks?* This field is required.
YESNO
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What do some of your hobbies include?Outdoor or Indoor?
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Do you ever experience these conditions on your skin?* This field is required.
flakiness
tightness
obvious dryness
overly shiny
dry patches
clogged pores/blackheads
enlarged pores
Other
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Do you have a tendency to redness?
YESNO
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Do you experience breakouts on your face?* This field is required.
Yes
No
Sometimes
Only on my cycle
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Within the last year, have you been under a dermatologist care?* This field is required.
YESNO
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Medical HistoryPlease check all that apply
Check if applies
Herpes Simplex
Row 0, Column 0
Eczema
Row 1, Column 0
Psoriasis
Row 2, Column 0
Hepatitis
Row 3, Column 0
HIV/AIDS
Row 4, Column 0
Hemophilia
Row 5, Column 0
Thyroid
Row 6, Column 0
Problems Lupus
Row 7, Column 0
Hormone Problems
Row 8, Column 0
Anemia
Row 9, Column 0
Hysterectomy
Row 10, Column 0
High Blood Pressure
Row 11, Column 0
Cancer
Row 12, Column 0
Ovary(ies) Removed
Row 13, Column 0
Diabetes
Row 14, Column 0
Staph Infection/MRSA
Row 15, Column 0
Pacemaker
Row 16, Column 0
Metal Pins in Body
Row 17, Column 0
Herpes Simplex
Eczema
Psoriasis
Hepatitis
HIV/AIDS
Hemophilia
Thyroid
Problems Lupus
Hormone Problems
Anemia
Hysterectomy
High Blood Pressure
Cancer
Ovary(ies) Removed
Diabetes
Staph Infection/MRSA
Pacemaker
Metal Pins in Body
Check if applies
Row 0, Column 0
Check if applies
Row 1, Column 0
Check if applies
Row 2, Column 0
Check if applies
Row 3, Column 0
Check if applies
Row 4, Column 0
Check if applies
Row 5, Column 0
Check if applies
Row 6, Column 0
Check if applies
Row 7, Column 0
Check if applies
Row 8, Column 0
Check if applies
Row 9, Column 0
Check if applies
Row 10, Column 0
Check if applies
Row 11, Column 0
Check if applies
Row 12, Column 0
Check if applies
Row 13, Column 0
Check if applies
Row 14, Column 0
Check if applies
Row 15, Column 0
Check if applies
Row 16, Column 0
Check if applies
Row 17, Column 0
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Please indicate if you have used any of the medications or drugs listed below in the last 2 years...when they were used, and for how long you used them
Last used date
How Long used
Drug Name (s)
Antibiotics (Oral)
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Antibiotics (Topical)
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Accutane
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Benzoyl Peroxide
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Retin-A, Tazorac, Differen
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Thyroid Medication
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Blood Thinners
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Antibiotics (Oral)
Antibiotics (Topical)
Accutane
Benzoyl Peroxide
Retin-A, Tazorac, Differen
Thyroid Medication
Blood Thinners
Last used date
Row 0, Column 0
How Long used
Row 0, Column 1
Drug Name (s)
Row 0, Column 2
Last used date
Row 1, Column 0
How Long used
Row 1, Column 1
Drug Name (s)
Row 1, Column 2
Last used date
Row 2, Column 0
How Long used
Row 2, Column 1
Drug Name (s)
Row 2, Column 2
Last used date
Row 3, Column 0
How Long used
Row 3, Column 1
Drug Name (s)
Row 3, Column 2
Last used date
Row 4, Column 0
How Long used
Row 4, Column 1
Drug Name (s)
Row 4, Column 2
Last used date
Row 5, Column 0
How Long used
Row 5, Column 1
Drug Name (s)
Row 5, Column 2
Last used date
Row 6, Column 0
How Long used
Row 6, Column 1
Drug Name (s)
Row 6, Column 2
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Please list any other medications or drugs listed that you have used in the past 2 years and include when* This field is required.If none, type NONE
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Diet: Do you consume any of the following?
Yes
How often per week?
Fast Food
Row 0, Column 0
Row 0, Column 1
Peanuts
Row 1, Column 0
Row 1, Column 1
Processed Food
Row 2, Column 0
Row 2, Column 1
Sushi
Row 3, Column 0
Row 3, Column 1
Salty Snacks
Row 4, Column 0
Row 4, Column 1
Kelp and Seaweed
Row 5, Column 0
Row 5, Column 1
Milk/Yogurt
Row 6, Column 0
Row 6, Column 1
Miso Soup
Row 7, Column 0
Row 7, Column 1
Cheese
Row 8, Column 0
Row 8, Column 1
Soy
Row 9, Column 0
Row 9, Column 1
Whey or Soy Protein
Row 10, Column 0
Row 10, Column 1
Vitamins/Supplements
Row 11, Column 0
Row 11, Column 1
Peanut Butter
Row 12, Column 0
Row 12, Column 1
Seafood
Row 13, Column 0
Row 13, Column 1
Fast Food
Peanuts
Processed Food
Sushi
Salty Snacks
Kelp and Seaweed
Milk/Yogurt
Miso Soup
Cheese
Soy
Whey or Soy Protein
Vitamins/Supplements
Peanut Butter
Seafood
Yes
Row 0, Column 0
How often per week?
Row 0, Column 1
Yes
Row 1, Column 0
How often per week?
Row 1, Column 1
Yes
Row 2, Column 0
How often per week?
Row 2, Column 1
Yes
Row 3, Column 0
How often per week?
Row 3, Column 1
Yes
Row 4, Column 0
How often per week?
Row 4, Column 1
Yes
Row 5, Column 0
How often per week?
Row 5, Column 1
Yes
Row 6, Column 0
How often per week?
Row 6, Column 1
Yes
Row 7, Column 0
How often per week?
Row 7, Column 1
Yes
Row 8, Column 0
How often per week?
Row 8, Column 1
Yes
Row 9, Column 0
How often per week?
Row 9, Column 1
Yes
Row 10, Column 0
How often per week?
Row 10, Column 1
Yes
Row 11, Column 0
How often per week?
Row 11, Column 1
Yes
Row 12, Column 0
How often per week?
Row 12, Column 1
Yes
Row 13, Column 0
How often per week?
Row 13, Column 1
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Do you have any special skin problems or diagnosis pertaining to your face or body? If yes, please specify* This field is required.
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Are you pregnant?* This field is required.
YESNO
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Do you use birth control pills, shots or use an IUD?* This field is required.
YESNO
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Are you Diabetic?* This field is required.Diabetics can have numerous skin conditions
Type 1
Type 2
No
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How would you describe your skin type?* This field is required.
Dry
Oily
Sensitive
Combination
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Have you ever had a reaction to any of the following?* This field is required.
cosmetics or adhesives
medications
Aspirin
Sulfur
Latex
iodine
pollen or grass
food
hydroxy acids
animals
fragrance
sunscreens or tanner
NONE
other
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Do you burn easily in the sun?* This field is required.
YESNO
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Have you ever had any reaction to any products or anything you have put on your face?* This field is required.
YESNO
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What skin care products are you currently using?* This field is required.check ALL items you are currently using
nothing/just water
bar soap on face
shower gel on face
facial cleanser
exfoliator, Acids or scrubs for face
toner
facial moisturizer
sunscreen
masque
facial serum
eye products
face oil
body moisturizer, oil or lotion on face
depilatory products on face (i.e. Nair)
beard oil
shampoo on beard
Alcohol
Peroxide
Foundation
Acne Medications
Tretinoin
Other
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Other Treatments: What other treatments have you had in the past 90 days?
When?
Where?
Chemical Peels
Row 0, Column 0
Row 0, Column 1
If so, what kind:
Row 1, Column 0
Row 1, Column 1
Microdermabrasion
Row 2, Column 0
Row 2, Column 1
Dermaplane
Row 3, Column 0
Row 3, Column 1
Laser Hair Removal
Row 4, Column 0
Row 4, Column 1
Laser Rejuvenation/Resurfacing
Row 5, Column 0
Row 5, Column 1
Skin Cancer Removal
Row 6, Column 0
Row 6, Column 1
Facial Waxing
Row 7, Column 0
Row 7, Column 1
Electrolysis
Row 8, Column 0
Row 8, Column 1
Other:
Row 9, Column 0
Row 9, Column 1
Chemical Peels
If so, what kind:
Microdermabrasion
Dermaplane
Laser Hair Removal
Laser Rejuvenation/Resurfacing
Skin Cancer Removal
Facial Waxing
Electrolysis
Other:
When?
Row 0, Column 0
Where?
Row 0, Column 1
When?
Row 1, Column 0
Where?
Row 1, Column 1
When?
Row 2, Column 0
Where?
Row 2, Column 1
When?
Row 3, Column 0
Where?
Row 3, Column 1
When?
Row 4, Column 0
Where?
Row 4, Column 1
When?
Row 5, Column 0
Where?
Row 5, Column 1
When?
Row 6, Column 0
Where?
Row 6, Column 1
When?
Row 7, Column 0
Where?
Row 7, Column 1
When?
Row 8, Column 0
Where?
Row 8, Column 1
When?
Row 9, Column 0
Where?
Row 9, Column 1
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Have you ever used any Face Reality Skincare products?* This field is required.
YESNO
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Do you smoke/vape?* This field is required.
Yes, Cigarettes
Yes, Marijuana socially
Yes, Marijuana regularly
Yes, Vape
Recently quit Maijuana
Recently quit cigarettes
Recently quit vaping
No, nothing at all
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Do you use fabric softener or dryer sheets?
YESNO
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Are you currently under a lot of stress?* This field is required.Common stress triggers: job loss, new job, wedding, death in the family or close friend, graduation, long commute, heavily scheduled
YESNO
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What are your skin care goals?* This field is required.
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Please upload a makeup free photo from the neck up* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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I authorize my esthetician at Rosetreatment Room herein after collectively referred to as my “Esthetician" to perform skincare services on my face and/or body. I acknowledge that my esthetician has explained to me the methods and procedures concerning the services I have requested. I hereby consent to the services at my own risk. If at any time I am uncomfortable with the service, I will inform my esthetician and they will use good faith efforts to rectify the problem, including ending the service if I, or my esthetician sees fit. If my esthetician is uncomfortable with any service, they will discuss their concerns with me and may end the session if necessary. I acknowledge that I have received no guarantees, warranties, promise, and/or commitments regarding the service or the products used or applied therein or other statements as to the results of this service. I have revealed or disclosed all conditions and circumstances regarding my health and health history, medications being taken and any past reactions to products used or medications taken. Additional conditions could occur or be discovered during or after the procedure, which could affect my ability to tolerate the procedure.

I, THE UNDERSIGNED, HEREBY FULLY RELEASE, WAIVE, COVENANT NOT TO SUE, AGREE TO HOLD HARMLESS, AND FOREVER DISCHARGE my esthetician, companies associated with them, from any and all liabilities, demands, claims, losses, injuries, or damages, including court costs and attorneys’ fees and expenses, of any nature arising out of skincare services rendered, EVEN THOUGH CAUSED IN WHOLE OR IN PART BY A PRE- EXISTING DEFECT, THE NEGLIGENCE (WHETHER SOLE, JOINT OR CONCURRENT), GROSS NEGLIGENCE, STRICT LIABILITY OR OTHER LEGAL FAULT OF MY Esthetician OR OF Rosetreatment Room. I understand that RoseTreatment Room does not offer refunds for serives rendered. IT IS MY EXPRESS INTENT THAT THE ABOVE RELEASE INCLUDES THE RELEASE OF MY Esthetician (INCLUDING THE INDIVIDUALS AND ENTITIES LISTED ABOVE) FROM THE CONSEQUENCES OF THEIR OWN NEGLIGENCE. It is also my express intent that this Waiver and Release Form shall bind the members of my family and spouse, if I am alive, and my heirs, assigns and personal representatives, if I am deceased, and shall be governed by the laws of the State of Georgia.
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Please read the following statements and check and sign indicating that you understand, and accept the following statements:* This field is required.
I, the undersigned client, certify that I have read and had explained to me and fully understand the above waiver and release form and am signing it voluntarily as my own free act and deed. I certify that I have consulted with my esthetician and have read all applicable literature given to me. I have completed the Client Consultation Form (or verbal consultation) to the best of my knowledge. I accept the explanation of potential complications and risks described herein. I certify I am of sound mind and I am fully capable of executing this waiver and release form for myself. No Oral representations, statements, or inducements apart from the foregoing agreement that has been reduced to writing have been made.
I fully understand that there might be other unknown risks not reasonably foreseeable at this time and if receiving a service with blades, needles or sharp objects, there is a risk of breaking the skin.
I, for the purposes of documentation, hereby consent to “before and after” photographs.
I, give my esthetician the absolute right and unrestricted permission to take, use, and display photographic images of me, through and form of media (print, digital, electronic, broadcast, or otherwise) at any location for art, advertising, media release news articles, marketing, publicity, archival, or any other lawful purpose unless otherwise stated. I waive any right to royalties or other compensation arising from or related to the use of photographic images of me. I release and agree to hold harmless Rosetreatment Room and its affiliates from any liability in connection to taking or using said images.
I give consent to be signed up for the RoseTreatment Room newsletters and email updates.
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Signature* This field is required.
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Date* This field is required.
Date
Month
Day
Year
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