New Client Consultation Form

Skin Consultation

The more information you give us the more we can help you with your skin concerns
Name *

First Name Last Name
Date of Birth *
Your Skin
Within the last year, have you been under a doctors or experienced any health problems that have affected or could affect your skin? *

Yes No
What are your skin care goals? *
What are your skin care challenges? *

Wrinkles / Fine Lines Hyperpigmentation / Sun Damage Acne / Acne Scarring Redness / Rosacea Glycation (cross cross wrinkles) Melasma Sensitivity Dryness blackheads broken capillaries sensitivity Open pores Oiliness Loss of elasticity Cysts milia( whiteheads) Sallow (yellow/dull skin)
When did you first start to notice these concerns?
Do you notice your skin concern gets worse at any time of the day/month/year?
What Skin Care Products do you currently use? *

Cleanser / Face Wash Bar Soap Face Scrub / Exfoliants Toner Serums Moisturizer Sunscreen Eye Product(s) Lip Product(s)
If you are seeking corrective treatments please detail the SPECIFIC products (BRAND & PRODUCT TYPE/NAME) you are currently using so I can best answer any questions on ingredients and help you meet your skin care goals.
Cleanser / Face Wash
Bar Soap
Face Scrub / Exfoliants
Toner
Serums
Moisturizer(s)
Sunscreen
Eye Product(s)
Lip Product(s)
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 using Yes, but not within the last 30 days Yes, but not within the last 6 months No Not sure
Please specify which product or type, if you answered 'Yes, currently using' to above.
Have you received any of these hair removal services in the last 30 days? *

Waxing Sugaring Threading Electrolysis / Laser Depliatory Cream Shaving None
If checked, please note last time.
Have you ever received chemical peels, laser services, or microdermabrasion treatments? *

Yes, within the last month Yes, within the last 2-3 months No
Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks? *

Yes No
Your Health
Have you experienced any of these health conditions in the past or present? *

Hormone Imbalance Cancer / Systemic Disease High Blood Pressure Diabetes Heart problem Arthritis Auto-Immune Disorders Asthma Epilepsy / Seizure Disorder Fever Blisters Herpes Frequent Cold Sores HIV/AIDS Lupus Depression/Anxiety Hepatitis Headaches / Migraines Other None
If you checked yes to any of these please provide further information. If not mark N/A *
Do you? *

Wear contact lenses Have a pacemaker Have metal implants Have body piercings No, not Applicable
Do you take any of the following dietary / health supplements?

Multivitamin Vitamin C Vitamin D/D3 Zinc Omega 3 / Fish Oil B Complex / B12 Garlic Calcium Folic Acid Melatonin Coenzyme Q10 Biotin Other
If other, please list
Any known allergies? *

Aspirin Tree Nuts Latex Dairy Fruits Vegetables Shellfish Iodine Fragrances / Essential Oils Other None
If Other, please specify
Have you used or been prescribed any medications (topical or oral) for acne / acne control? *

Yes No
If yes, please specify what and date last used
Are you a smoker? *

Yes No Social
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks) *

Yes No
Have you ever experienced claustrophobia? *

Yes No
Please rate your stress level *

Low Medium High
FEMALE CLIENTS
Are you taking birth control? *

Yes No N/A
If yes, what kind
Are you pregnant or trying to become pregnant? *

Yes No Recently had a baby and and breastfeeding N/A
Any menopause issues? *

Yes No N/A
If yes, please specify
Are you undergoing any hormone replacement therapy?

Yes No
If yes, please specify
MALE CLIENTS
What is your current shaving system? *

Razor / Wet shave Electric N/A
Do you experience irritation from shaving? *

Yes No N/A
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 this skin care professional from liability and assume full responsibility thereof.

Yes
Signature *

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Date *

Month Day Year
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Skin Consultation

Your Skin

Your Health