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.**

Date

Name

First NameLast Name

Birth Date

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?

Name of Referral

Please Specify "Other"

Skin Type

What Are Your Skin Care Goals?

What Are Your Skin Care Challenges?

Additional Details Regarding Skin Care Challenges

Areas of Concern

Have You Had a Facial or Skin Care Treatment Before?

Approximate Date of Last Facial or Treatment

Frequency of Exfoliation (With a Scrub or Chemical Exfoliant)

What Skin Care Products Do You Currently Use?

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?

Specify Which Product

Do You Use Any Alpha Hydroxy Acid (Glycolic, Lactic, etc.) or Beta Hydroxy Acid (Salicylic) Products on a Regular Basis?

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

Approximate Date of Hair Removal Service

Date

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

Specify Which Treatment

Have You Received Botox, Juvederm, or Other Dermal Fillers in the Last Two Weeks?

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

Please Explain Reaction

Have You Experienced Any of These Health Conditions?

Please Provide Additional Information

Do You...

Do You Eat Any of These on a Regular Basis?

Do You Take a Probiotic Supplement?

Medications Currently Using

Illness/Conditions Currently Being Treated for by a Medical Professional

Allergies

Please Specify "Other"

Do You Use Any Prescription Medication (Topical or Oral) for Acne?

Provide Name of Medication

Date Last Used

Date

Do You Smoke?

Female Clients:

Are You Taking Birth Control?

Are You Pregnant or Trying to Become Pregnant?

Do You Have Eyelash Extensions?

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.

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%

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.

Please list any additional information that you believe is necessary for us to know.

Areas NOT to Massage During Service

Signature

New Client Consultation Form

Your Skin

Your Health