Skincare Service Consultation Form

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

First NameLast Name
What is your preferred pronoun?
If Other, please specify
Phone Number
City/State
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
MM/DD/YYYY
How did you hear about us?

Other
If you were referred, please place their name here (type N/A if not applicable):
Your Health & Wellness
Within the last year, have you been under a dermatologist’s or other physician’s care?
If yes, please specify
Have you had any health problems in the past 12 months?
If yes, please specify
List any medications, supplements, vitamins, diuretics, Isotretinoin, etc. that you take regularly:
Do you smoke?
Do you exercise regularly?
Do you follow a strict diet?
Your level of stress (1 being the lowest, 10 being the highest)
Do you have any allergies? Including to food and medicine i.e. Asprin, seafood, apricot, berries, etc.
If yes, please specify
Have you ever had an allergic reaction to aspirin?
Do you sunbathe or use tanning beds?
Do you drink more than 4 caffeinated beverages daily?
Approximately how much water IN OUNCES do you drink daily?
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.
How would you describe your sleep quality?
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.
Have you experienced any of the following in the last 6-12 months? Please check all that apply.
How often do you exercise?
Do you have metal implants, a pacemaker or facial piercings?
Do you have a known heart conditions?
Have you received IV Infusion Therapy in the past?
Beyond your skin, what are you hoping to improve over the next 3 months? (check all)
Would you also like to be evaluated for IV therapy? Your provider can discuss support for skin clarity, even tone and firmness, along with hydration, energy, immune, antioxidant and recovery support. No additional costs associated.
Your Skin
Have you ever experienced keloids or hypertrophic scars?
Have you had fillers, threads, or botox in the last 6 months?
Have you had plastic surgery in the last 12 months?
What are your skin goals?
What are your specific concerns or challenges with your skin? Check all that apply

Other
Are you interested in removing any of the following skin irregularities?
IF YOU HAVE SELECTED AN OPTION ABOVE, PLEASE UPLOAD A PHOTO OF THE SKIN IRREGULARITY.

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Are you currently experiencing hormonal shifts, irregular cycles, or perimenopause symptoms?
Have you noticed your skin changing in the last 1-2 years in ways your current routine isn't addressing?
Are you currently on HRT, birth control, or any hormone-related medication?
Using the chart and descriptions above, please select your skin type:
Have you had a chemical peel, microdermabrasion, laser or light therapy, and injectable or other cosmetic procedure in the last month?
Do you use Retin-A, Renova, Adapalene, or any other prescription skin products in the last three months?
Have you ever used any products with Benzoyl Peroxide?
Have you taken isotretinoin (Accutane) within the last 6-12 months?
Are you currently using any products that contain the following ingredients? Select all that apply. If yes, please select below.
Do you ever experience these conditions?
Do you use SPF on your skin?
Do you burn easily in moderate sunlight?
Are you currently experiencing a breakout?
If yes, where do you have your breakouts the most?
How often do you break out, if at all?
If you have breakouts, are the breakouts mostly:
When you break out, approximately how many lesions (aka pimples or bumps) would you say you have at once?
What skin care products are you currently using? Select all that apply.

Other
Additionally, please list your current skincare routine (if any). Including any cleansers, soaps, moisturizers, serums, etc.
Are you taking oral contraception?
Are you pregnant or trying?
Are you lactating?
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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.
I have read and agreed to Crystal Ngozi Beauty & Esthetic's policies: https://crystalngozibeauty.com/policies/
Add any additional notes here:
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Skincare Service Consultation Form

Your Health & Wellness

Your Skin

Reference Files