New Client Consultation Form

New Client Intake Form
Current Date*

MonthDayYear
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState

Zip
Mobile Number*

Area CodePhone Number
E-mail*
example@example.com
Gender assigned at birth*
Pronouns*
How did you hear about Nomadic Skincare?*

Website / Online SearchFacebookInstagramReferralI know Maddie!Other
If Referral, please list name
If Other, specify
Occupation *
Do you work nights?*

YesNo
Do you agree that Nomadic Skincare can use images of you and any before, after, or progression photos of any services performed for marketing, portfolio and website content purposes?*

yesno
Your Skin Health and History

How do you currently feel about the quality of your skin?*

	1	2	3	4	5	6	7	8	9	10

1 is Bad, 10 is Great

What do you feel is your skin type?*

NormalOilyDry/DehydratedAcne ProneSensitiveCombination
Please describe your primary reason for seeking treatment from an esthetician:
What are your current skin concerns? (select all that apply)*

Red/ Inflammed AcneUneven ToneCongested PoresFine Lines/WrinklesAcne ScarringHyperpigmentation/Sun DamageDryness/DehydrationRedness/InflammationRosacea/SensitivityOther
What Skin Care Products do you currently use? (select all that apply)*

Cleanser / Face WashBar SoapFace Scrub / Physical ExfoliantsAHA/BHATonerSerumsNight Creme/MoisturizerSunscreenEye CremeLip TreatmentsMakeup Removers
If possible, please list the names of the products you use on a regular basis;
When you go out in the sun, do you...*

Always Burn (I)Usually Burn (II)Sometimes Burn (III)Rarely Burn (IV)Never Burn (V)
Have you ever had a facial or skin treatment before?*

YesNo
If Yes, when was your most recent treatment (month and year)?
Have you received any of the following facial treatments in the past 3 months?*

Chemical Peel or Peel SeriesLaser TreatmentsLED Light TherapyPRP TreatmentsMicroneedlingDermaplaneMicrodermabrasionNoneHydraFacial
Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?*

Yes, currently usingYes, but not within the last 30 daysYes, but not within the last 6 monthsNoNot sure
Please specify which product or type, if you answered 'Yes, currently using' or 'Yes, but not within the past 30 days' to above.
Have you received any Botox, Juvederm, Collagen, or other dermal fillers in the past month?*

YesNo
If yes, please describe:
Have you been under the treatment plan of a dermatologist or plastic surgeon in the past year?*

YesNo
If yes, please describe:
Your Health
Do you have a history of or are you currently experiencing any of the following conditions? (check all that apply)*

Hormone ImbalanceCancer / Systemic DiseaseHigh or Low Blood PressureDiabetesSkin Disorders/DiseaseHeart problemsArthritisAuto-Immune DisordersAsthmaHypertensionEpilepsy / Seizure DisorderFever BlistersHerpesFrequent Cold SoresHIV/AIDSLupusDepression/AnxietyHepatitisHeadaches / MigrainesOtherNone
If you checked YES to any of these please provide further information.
Do you:*

Wear contact lensesHave a pacemakerHave metal implantsHave body piercingsUse a tanning bedNone of the Above
Please list all of your current medications:
Do you take any of the following dietary / health supplements?

MultivitaminVitamin CVitamin D/D3ZincOmega 3 / Fish OilB Complex / B12GarlicCalciumFolic AcidMelatoninCoenzyme Q10BiotinOther
If other, please list
Any known topical or relevant allergies?*

AspirinTree NutsLatexDairyFruitsVegetablesShellfishIodineFragrances / Essential OilsOtherNone
If Other, please specify
Have you used or been prescribed any medications (topical or oral) for acne / acne control?*

YesNo
If yes, please specify what and date last used
Are you a cigarette smoker?*

YesNoSocial
How much alcohol do you consume in a week?*

0-2 beverages3-5 beverages6-10 beveragesMore than 10 alcoholic beverages
Do you drink more than 2 caffeinated beverages a day? (tea, coffee, soda, energy drinks)*

YesNo
Have you ever experienced claustrophobia? *

YesNo

Please rate your current level of stress:*

	1	2	3	4	5	6	7	8	9	10

1 is Very Chill, 10 is Very Stressed

FEMALE CLIENTS
Are you taking birth control? *

YesNoN/A
If yes, what kind
Are you pregnant or trying to become pregnant?*

YesNoRecently had a baby and am breastfeedingN/A
If yes, please specify
Are you undergoing any hormone replacement therapy? *

YesNo
If yes, please specify
Post Facial Care/Waxing Instructions: Aerobic exercise and/or vigorous physical activity should be avoided for 24-72 hours depending on treatment. 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.*

I have read the post care instructions and agree to adhere to them.
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 Nomadic Skincare LLC and all affiliated skin care professionals from liability and assume full responsibility thereof.

Yes
Signature*

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New Client Intake Form

Your Skin Health and History

Your Health