New Client Consultation Form

New Acne Client Consultation Form
This form is for clients to fill out prior to their INITIAL ACNE appointment. If you are coming in for any service OTHER THAN the Initial Acne Consult or Treatment, I need you to fill out a different form! Please fill out my Informed Consent (https://kyannemarie.com/informed-consent) form if you are coming in for a service other than the Initial Acne Consult or Acne Treatment.

If you are coming in for your INITIAL ACNE CONSULTATION or ACNE TREATMENT, then please fill out the form below in entirety prior to your appointment so that I can serve you best, thank you!
*

I am an acne client
Name*

First NameLast Name
Date of Appointment

MonthDayYear
Date of Birth*

MonthDayYear
Current Age*
Parent or Guardian
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
How did you hear about us?*

Website / Online SearchInstagramFacebookReferralOther
If Referral, please list name (We have a Referral Program!)
Is your consultation in person, or remote?*

In personRemote
For remote consults, I need 3 excellent pictures of your skin! In good lighting, please take a picture of:

- the left side of your face in profile,

- the right side of your face in profile,

- and a picture straight on the front of your face.
Take Photo
Take Photo
Take Photo
Medical History

Medications

Rows	Currently Using?	Past?	How long / When
Antibiotics
Accutane
Benzoyl Peroxide
Retin A
Tazorac
Differin
Azelex
Avita
Cleocin-T
E-mycin-T
Copaxone
Corticosteroids
Quinine
Androstendione
Testosterone
Progesterone
Thyroid
Gonadotrophin
Danzol
Cyclosporin
Lithium
Isoniazid
Immuran
Disulfuram
Dialntin/Tegretol
Steroids
Marijuana
Cocaine/Speed
Other Meds

Do you take any of the following dietary / health supplements? (Please check all that apply)

MultivitaminVitamin CVitamin D/D3ZincOmega 3 / Fish OilB Complex / B12GarlicCalciumFolic AcidMelatoninCoenzyme Q10BiotinOther
Medical History (please check all that apply)

Herpes SimplexEczemaPsoriasisHepatitisCancerStaph Infection / MRSAHIV / AIDSThyroid ProblemsHormone ProblemsHysterectomyOvary(ies) RemovedPacemakerHemophiliaLupusAnemiaHigh Blood PressureDiabetesMetal Pins in Body
Are you under a dermatologists' or other physician's care?*

YesNo
If yes, Doctor's Name
If yes, Doctor's Phone Number
Lifestyle Considerations
Have you ever had any reaction to any products or anything you have put on your face?*

YesNo
If yes, what products?
Please check if you are you allergic to:

SulfurAspirinLatex
List any other allergies you know of:
Do you smoke?*

YesNo
Do you use fabric softener or dryer sheets?*

YesNo
Do you swim in a chlorinated pool?*

YesNo
Do you work around chemicals, tars, oils, grease, or inks?*

YesNo
Occupation*
Do you work nights?*

YesNo
Please rate your stress level*

LowMediumHigh
Do you use birth control pills, shots, or an IUD?*

YesNoNot applicable
If yes, which type of birth control do you use?
Which brand?
Are you pregnant or nursing?*

YesNoNot applicable
Do you have shaving irritation?*

YesNoNot applicable
If yes, what type of razor do you use for shaving?

Diet - do you consume the following?*

Rows	Yes	How Often Per Week
Fast Food
Processed Food
Salty Snacks
Milk / Yogurt
Cheese
Whey or Soy Protein
Peanut Butter
Peanuts
Sushi
Kelp and Seaweed
Miso Soup
Soy
Vitamins Seafood

Your Skin
What are your skin care goals? *
What are your skin care challenges?*

Wrinkles / Fine LinesHyperpigmentation / Sun DamageAcne / Acne ScarringRedness / RosaceaAgingMelasmaSensitivityOther
Please feel free to go into more detail:
Have you ever had a facial or skin treatment before?*

YesNo
If Yes, when?

Products Currently Using - please provide product names*

Rows	Yes	Product Name
Cleanser
Toner
Serums
Moisturizers
Sunscreen
Mask(s)
Exfoliant (acids, serums, scrubs)
Foundation
Blush
Acne Medications
None of the above

Any other current products?

Other Treatments: What else have you done for your skin in the last 90 days?

Rows	Yes	When?	Where? (face/neck/chest/etc)	Service provider? (spa/clinic name)
Chemical Peels
Microdermabrasion
Dermabrasion
Laser Hair Removal
Laser Rejuvenation/Resurfacing
Skin Cancer Removal
Facial Waxing
Electrolysis
Botox, Juvederm, or other filler
Other

Reservation & Cancellation Policy for all current and future appointments: 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 24 hours prior to appointment a cancellation fee of 50% of the reserved service booking will incur. (Except in cases of contagious illness as described below.) No Shows will be charged 100%*

I understand the reservation and cancellation policies at Kyanne Marie Skin Care and consent to my credit card on file being charged if I fail to give 24 hour notice for appointments.
If you, or another person in your household, has an infectious or contagious illness, please contact us as soon as possible to reschedule your appointment for a later date. There is no penalty or time-frame required in this case, for your safety and that of other clients.*

I understand
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 at least SPF 28. Sunscreen (with a minimum SPF 28) 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, dermaplane treatments, chemical peels, sugaring, or 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.
COVID-19 INFORMATION

COVID-19 is a highly contagious virus that spreads from person to person. In addition to long-held and explicit sanitation measures this business has always adhered to, new preventative measures have been put in place to further reduce the spread of this novel coronavirus. However, these best practices still offer no guarantee regarding your potential risk of being infected.
Please indicate that you agree to cancel any appointment as soon as possible if you experience any of the following:*

A fever of 100°F or above 48 hours prior to your appointmentAny respiratory or flu symptoms, sore throat, or shortness of breathBeen in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptomsI understand that, because esthetics involves maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. By signing this form, I acknowledge that I am aware of the risks involved from receiving treatment at this time, I voluntarily agree to assume those risks, and I release and hold harmless the practitioner/business from any claims related thereto. I give my consent to receive treatment from this practitioner.
I understand that, because esthetics involves maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. By signing this form, I acknowledge that I am aware of the risks involved from receiving treatment at this time, I voluntarily agree to assume those risks, and I release and hold harmless the practitioner/business from any claims related thereto. I give my consent to receive treatment from this practitioner.*

I understand
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.*

Yes
Newsletter

Yes, subscribe me to The Sugar Coated Sugar and Skin™ newsletter.
The Sugar Coated Sugar and Skin™ is located at:

358 Holladay Ct.
Loveland, CO 80537

Please park in front of the third stall in the driveway or in the center parking.

Text me at (970) 460-8801 when you get there, and I'll let you know when you can come inside!
*

Got it, I’ll wait in my car and text Kyanne at (970) 460-8801 when I arrive
Client Name

First NameLast Name
Client Signature*
Parent or Guardian Name (if client is under 18)

First NameLast Name
Parent or Guardian Signature (if client is under 18)
Should be Empty:

New Acne Client Consultation Form

Medical History

Lifestyle Considerations

Your Skin

COVID-19 INFORMATION

Please park in front of the third stall in the driveway or in the center parking.

Text me at (970) 460-8801 when you get there, and I'll let you know when you can come inside!