Client Consultation Form By Patrick Santa Ana

Date

MonthDayYear

Name

First NameLast Name

Phone Number

Area CodePhone Number

Email

example@example.com

Referred by:

What is your overall concerns and goals for this treatment?

YOUR SKIN

1) Have you ever had a facial before? If yes, please specify

2) Do you have any special skin problems or concerns pertaining to your face or body? If yes, please specify

3) Do you use Retin-A, Renova, AHA or Retinol derivative products? If yes, please specify

3a) Have you used any of the previously listed products in the last 3 months? If yes, how long ago?

4) Have you ever had chemical peels, laser or microdermabrasion? If yes, when?

5) Have you ever used an acne medicine? If yes, when?

5a) Which drug?

6) What skin care products are you currently using?

Rows	List brand where known
Face Soap/Cleanser
Toner
Day Moisturizer
SPF
Eye Product
Exfoliator/Scrub
Mask
Night Moisturizer
Other

Area of Concern - SKIN:

Rows	Check all that apply
Breakouts/ Acne
Blackheads/ Whiteheads
Excessive Oil/ Shine
Eczema
Psoriasis
Dehydration/moisture
Wrinkles/ Elasticity

Signature

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previ- ous 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 institution and/or skin care profes- sional from liability and assume full responsibility thereof.