Skincare Service Consultation Form
As an Integrative Esthetics Practice, our philosophy is that your skin health is a 360 approach. While other professionals choose to throw products and medications at the problem, We like to take a more integrative approach and meet your skin concerns at their core. During this time, we will dig deep into the possible causes of your acne or skin concerns including diet, lifestyle, genetics, etc. At the conclusion of our time together, you will receive a clear and complete road map on how together we can achieve your desired results!
Name
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First Name
Last Name
What is your preferred pronoun?
Please Select
She / Her / Hers
He / Him / His
They / Them / Theirs
Other
If Other, please specify
Phone Number
*
City/State
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Email Address
*
I will be following up with you on how to begin via email so please use the address you check most frequently! I will never sell your email or spam.
Date of Birth
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MM/DD/YYYY
How did you hear about us?
*
Facebook Ad
Instagram Ad
TikTok
Google Ad
Referral
Radio Ad
Mailer
Other
If you were referred, please place their name here (type N/A if not applicable):
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Your Health
Within the last year, have you been under a dermatologist’s or other physician’s care?
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Please Select
Yes
No
If yes, please specify
Have you had any health problems in the past 12 months?
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Please Select
Yes
No
If yes, please specify
List any medications, supplements, vitamins, diuretics, Isotretinoin, etc. that you take regularly:
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Do you smoke?
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Please Select
Yes
No
Do you exercise regularly?
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Please Select
Yes
No
Do you follow a strict diet?
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Please Select
Yes
No
Your level of stress (1 being the lowest, 10 being the highest)
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Please Select
1
2
3
4
5
6
7
8
9
10
Do you have any allergies? Including to food and medicine i.e. Asprin, seafood, apricot, berries, etc.
*
Please Select
Yes
No
If yes, please specify
Have you ever had an allergic reaction to aspirin?
*
Please Select
Yes
No
Do you sunbathe or use tanning beds?
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Please Select
Yes
No
Do you drink more than 4 caffeinated beverages daily?
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Please Select
Yes
No
Approximately how much water IN OUNCES do you drink daily?
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OUNCES
Do you eliminate at least once per day? This is an odd but relevant question for my clients with skin issues including Acne, Eczema, Psoriasis, etc.
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Yes
No
How would you describe your sleep quality?
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I feel like I get enough rest
I know that I need more rest
How would you describe your energy levels on a scale of 1-10. 10 being having the most energy. 1 having the least amount of energy daily.
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Have you experienced any of the following in the last 6-12 months? Please check all that apply.
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Decreased energy levels
Brain fog/lack of alertness
Digestive discomfort (heart burn, gas, stomach aches, diarrhea, constipation, etc.)
None of these
Do you have metal implants, a pacemaker or facial piercings?
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Yes
No
Do you have a known heart conditions?
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Yes
No
Your Skin
Have you ever experienced keloids or hypertrophic scars?
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Yes
No
Have you had fillers, threads, or botox in the last 6 months?
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Yes
No
Have you had plastic surgery in the last 12 months?
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Yes
No
What are your skin goals?
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What are your specific concerns or challenges with your skin? Check all that apply
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General Skin Health
Unwanted hair growth on lip, chin, face, cheeks, jawline, underarms, brazillian, bikini areas.
Acne
Hyperpigmentation (i.e. dark spots, etc.)
Wrinkles
Sagging skin
Fine Lines
Pore Size
Oily Skin
Dry Skin
Uneven skin tone
Rosacea
Other
Are you interested in removing any of the following skin irregularities?
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Skin Tags (often mistaken for moles)
Age Spots (often mistaken for freckles)
Sun Spots (often mistaken for freckles)
Milia
Small Spider Capillaries
Cherry Angiomas
Sebaceous Hyperplasia
Fibromas
Cholesterol Deposits
I am not interested or I do not have any of these skin irregularities.
IF YOU HAVE SELECTED AN OPTION ABOVE, PLEASE UPLOAD A PHOTO OF THE SKIN IRREGULARITY.
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Using the chart and descriptions above, please select your skin type:
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Very Dry
Dry
Normal
Oily
Very Oily
Combination of Oily and Normal/Dry
I'm not sure
Have you had a chemical peel, microdermabrasion, laser or light therapy, and injectable or other cosmetic procedure in the last month?
*
Please Select
Yes
No
Do you use Retin-A, Renova, Adapalene, or any other prescription skin products in the last three months?
*
Please Select
Yes
No
Have you ever used any products with Benzoyl Peroxide?
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Yes
No
I'm not sure
Have you taken isotretinoin (Accutane) within the last 6-12 months?
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Please Select
Yes
No
Are you currently using any products that contain the following ingredients? Select all that apply. If yes, please select below.
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Glycolic Acid
Lactic Acid
Exfoliating Scrub
Vitamin A
Other Acid ingredient
I am not using any of these ingredients
Do you ever experience these conditions?
*
Please Select
Flakiness
Tightness
Obvious Dryness
No
Do you use SPF on your skin?
*
Please Select
Yes
No
Do you burn easily in moderate sunlight?
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Please Select
Yes
No
Are you currently experiencing a breakout?
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Please Select
Yes
No
I NEVER break out
If yes, where do you have your breakouts the most?
How often do you break out, if at all?
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Continuous breakouts
During/Around menstrual cycle
A few times per month
A few times per week
Only when I eat certain things
NONE
I do not have breakouts
If you have breakouts, are the breakouts mostly:
Above the skin (such as white heads and pustules)
Below the skin (such as raised bumps under the skin)
A combination of both
When you break out, approximately how many lesions (aka pimples or bumps) would you say you have at once?
10 lesions or less
10 to 30 lesions
30+ lesions
What skin care products are you currently using? Select all that apply.
*
Soap
Cleanser
Toner
Moisturizer
Exfoliator
Serum
Eye Product
Other
Additionally, please list your current skincare routine (if any). Including any cleansers, soaps, moisturizers, serums, etc.
*
Are you taking oral contraception?
*
Please Select
Yes
No
N/A
Are you pregnant or trying?
*
Please Select
Yes
No
N/A
Are you lactating?
*
Please Select
Yes
No
N/A
Reference Files
Upload clear, well-lit, in focus photos of your affected area(s) here. Please upload a photo of the front and each sides of your face. Be sure to Include any acne, dry patches, hyper-pigmentation, scars, etc. (Please use reference photo below and try to submit similar photos). Please be sure to capture your FULL face in each shot.
NOTE: AT LEAST ONE PHOTO IS REQUIRED. IF YOU SKIP THE UPLOAD, THE FORM WILL NOT BE COMPLETE. A photo with no Makeup is ideal.
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I confirm that the information I have provided is accurate and complete. I understand that withholding relevant information may affect my treatment results, and I will not hold my Esthetician responsible for any adverse reactions. Marketing use will always require separate permission. I consent to Crystal Ngozi Beauty & Esthetics and its affiliates using my photos to monitor my progress and support future skincare research and technology development. Any data shared with partners will always be de-identified and will never include my name or personal details.I understand that this consent applies to all images captured during my treatments, including past and future appointments. By checking “I agree,” I acknowledge and accept all terms.
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I agree
I have read and agreed to Crystal Ngozi Beauty & Esthetic's policies: https://crystalngozibeauty.com/policies/
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I agree
Add any additional notes here:
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