New Client Consultation Form

NOTE: This form is required to be filled out prior to a client's first facial at Simply You Skincare & Wellness. **Clients MUST sign-up to be a client (using our Contact Us form) prior to completing this form, and/or have talked to Allie to schedule an appointment.**
New Client Consultation Form

Simply You Skincare & Wellness
Date*

MonthDayYear
Date
Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Email*
How Did You Hear About Us?*

Website/Online SearchInstagramFacebookReferralOther
Name of Referral
Please Specify "Other"
Your Skin
Skin Type*

DryNormalOilySensitiveCombination
What Are Your Skin Care Goals?*
What Are Your Skin Care Challenges?*

AcneAgingBlackheads/WhiteheadsHyperpigmentation/Sun DamageMelasmaRednessRosaceaScarringSkin Tone/TextureWrinkles/Fine LinesOther
Additional Details Regarding Skin Care Challenges
Areas of Concern*

FaceChestBack
Have You Had a Facial or Skin Care Treatment Before?*

YesNo
Approximate Date of Last Facial or Treatment
Frequency of Exfoliation (With a Scrub or Chemical Exfoliant)*

Daily2-3 Times Per WeekWeeklyMonthlyNeverNot SureOther
What Skin Care Products Do You Currently Use?*

CleanserScrub/ExfoliantTonerSerumsMoisturizerSunscreen
Please provide product specific information (brand and product name) for products that you use
Cleanser
Scrub/Exfoliant
Toner
Serum
Moisturizer
Sunscreen
Do You/Have You Used Retin-A, Accutane, or Another Vitamin A Derivative?*

Yes, Currently UsingYes, But Not Within the Last 30 DaysYes, But Not Within the Last 6 MonthsNoNot Sure
Specify Which Product
Do You Use Any Alpha Hydroxy Acid (Glycolic, Lactic, etc.) or Beta Hydroxy Acid (Salicylic) Products on a Regular Basis?

YesNoNot Sure
Have You Received Any of These Hair Removal Services in the Last 30 Days?*

WaxingSugaringThreadingElectrolysis/LaserDepliatory CreamShavingNone
Approximate Date of Hair Removal Service

MonthDayYear
Date
Have You Received Chemical Peels, Dermaplaning, Laser Services, or Microdermabrasion Treatments?*

Yes, Within the Last MonthYes, Within the Last 2-3 MonthsYes, Over 3 Months AgoNo
Specify Which Treatment
Have You Received Botox, Juvederm, or Other Dermal Fillers in the Last Two Weeks?*

YesNo
Have You Ever Had Any of the Following Adverse Reactions After Using a Skin Care Product?*

RashIrritationPeelingSun SensitivityBreakoutNone
Please Explain Reaction
Your Health
Have You Experienced Any of These Health Conditions?*

ArthritisAsthmaAuto-Immune DisordersCancer/Systemic DiseaseDiabetesEpilepsy/Seizure DisorderFever BlistersFrequent Cold SoresHeadaches/MigrainesHeart ProblemHepatitisHerpesHigh Blood PressureHIV/AIDSHormone ImbalanceLight SensitivityLupusOtherNone
Please Provide Additional Information*
Do You...*

Wear Contact LensesHave a PacemakerHave Metal ImplantsHave Body PiercingsNone
Do You Eat Any of These on a Regular Basis?*

DairyEggsGlutenRefined/Simple Carbs (White Bread/Pasta/Rice/Flour, etc)SugarWhey ProteinNone
Do You Take a Probiotic Supplement?*

YesNo
Medications Currently Using*
Illness/Conditions Currently Being Treated for by a Medical Professional*
Allergies*

AspirinTree NutsLatexDairyFruitsVegetablesShellfishIodineFragrances/Essential OilsOtherNone
Please Specify "Other"
Do You Use Any Prescription Medication (Topical or Oral) for Acne?*

YesNo
Provide Name of Medication
Date Last Used

MonthDayYear
Date
Do You Smoke?*

YesNo
Female Clients:
Are You Taking Birth Control?*

YesNoNot Applicable
Are You Pregnant or Trying to Become Pregnant?*

YesNoCurrently BreastfeedingNot Applicable
Do You Have Eyelash Extensions?*

YesNo
Post Facial Care 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 15) should become part of your daily skin care regimen as skin can potentially become more sensitize to the sun as a result of this treatment. 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. Consult your skin care professional before resuming topical treatments. Enzyme peels, chemical peels or facial waxing 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.
Cancellation Policy: A valid credit card is required for all appointments. Please do not forget to confirm your appointment when you receive your reminder. In the event of cancellations received less than 48 hours prior to appointment, a cancellation fee of $50 will be charged. No shows will be charged 100%*

I understand the Cancellation Policy at Simply You Skincare & Wellness and consent to my credit card on file being charged if I fail to give 48 hour notice for appointments.
Full Disclosure Statement*

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 skin care professional from liability and assume full responsibility thereof.
Before & After Pictures: I consent to “before and after” photographs for the purpose of documentation, potential advertising and promotional purposes.*

YesNo
Please list any additional information that you believe is necessary for us to know.
Areas NOT to Massage During Service*

EarsHeadShouldersAll are OK!
Signature*

Clear
Should be Empty:

New Client Consultation Form

Your Skin

Your Health