New Client Consultation Form

Name

First NameLast Name

Date of Birth

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

E-mail

How did you hear about me?

If Referral, please list name

What are your skin care challenges?

Have you ever had a facial or skin treatment before?

What Skin Care Products do you currently use?

Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?

Please specify which product or type, if you answered 'Yes, currently using' to above.

Have you ever received chemical peels, laser services, or microdermabrasion treatments?

Have you experienced any of these health conditions in the past or present?

If you checked yes to any of these please provide further information.

Do you have any known allergies?

Other

If Other, please specify

Have you ever experienced claustrophobia?

FEMALE CLIENTS

Are you pregnant or trying to become pregnant?

If yes, what kind

If yes, please specify

Suki Haus Esthetics strives on providing high quality, customized services for each and every guest. In order to ensure this experience, timing is everything. There needs to be enough time for each guest’s service, as well as extensive sanitation procedures after EVERY guest has left the room. Should you need to cancel or reschedule your appointment, please allow at least 24 hours in advance, so I may have the opportunity to schedule another guest. Cancellations and reschedules that occur on the same day of your appointment will be charged a “No Show” fee. Upon booking your appointment, a card must be provided on file. If a no call, no show happens, your card will be charged 100% of the scheduled service missed. For late arrivals, guests arriving 10 minutes late may be asked to reschedule and will be charged 50% of their service booked. Thank you for your understanding, and I appreciate your business.

I understand, have read and completed this questionnaire truthfully. I consent to receive any facial, waxing, or makeup service of my choose by Suki Haus Esthetics with payment in full. 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.

Signature

New Client Consultation Form

Your Skin

Your Health