New Client Consultation Form

New Client Consultation Form

To ensure a Luxe experience, please take a moment to complete the following information.
Date *

Month Day Year
Name *

First Name Last Name
Date of Birth *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number *

Area Code Phone Number
E-mail *
How did you hear about me? *

Website / Online Search Yelp Facebook Referral Other
If Referral, please list name
If Other, please let me know
Let's Talk Skin!
Briefly describe your skin care goals? *
Do you currently have any skin care challenges? *

Wrinkles / Fine Lines Hyperpigmentation / Sun Damage Acne / Acne Scarring Redness / Rosacea Aging Melasma Sensitivity Other
Please feel free to go into more detail
Have you ever had a facial or skin treatment before? *

Yes No
If Yes, when?
What Skin Care Products do you currently use? (Select all that apply) *

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

In order to ensure you are provided with a Luxe Experience we must understand your medical history to determine any contraindications. Please note this information is remain confidential.
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
Do you use a facial shaving system? *

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

Yes No N/A
Post Facial Care/Waxing Instructions: Aerobic exercise and/or vigorous physical activity should be avoided for 48 hours. 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, DermaFile or DermaDisc treatments, 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.
We understand that emergencies happen. If you need to cancel your appointment, we kindly ask that you notify us of any cancellations or rescheduling at least 24 hours prior to the appointment. Cancellations requested within the 24 hours of your scheduled service will result in a forfeit of 50% of your scheduled as a cancellation fee. In the case of missing your appointment, the 50% cancellation fee will apply. Two or more missed appointments equal being blocked from future appointments.In the event you need to cancel or reschedule your appointment, log into your Ava Luxe Beauty account and navigate to your personal My Bookings page. There you can view upcoming and past bookings. Each of the upcoming bookings has a Reschedule and Cancel option, so you may easily make changes. Note: Group Appointments/Parties (3 or more people) require at least 72 hours notice. *

I understand the reservation and cancellation policies at Ava Luxe Beauty Studio and consent to my credit card on file being charged if I fail to give 24 hour notice for appointments scheduled.
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
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New Client Consultation Form

Let's Talk Skin!

Your Health