New Client Consultation Form

Advance Clinical Facial

client consultation form
Date*

MonthDayYear
Appointment Date*

MonthDayYear
Name*

First NameLast Name
Date of Birth (mm/dd)*
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?*

Website / Online SearchInstagramFacebookReferralOther
If Referral, please list name
If Other, please let me know
Which services are you having done?

makeup applicationfacial treatmentwaxingbrow services (tint, wax, henna, lamination)weight management services (cavidation, laser lipo, RF, sauna wrap)
Your Skin
What are your skin care goals? *
What is your skin condition or concerns? (check all that apply)*

Wrinkles / Fine LinesHyperpigmentation / Uneven Skin ToneSun DamageAcne /BreakoutsExcessive Oil/ ShineFlaky SkinDull/ Dry SkinRedness / RosaceaComodones (Blackheads/ Whiteheads)Dehydrated/ Lacking MoistureAging/ Fine Lines/ WrinklesMelasmaSensitivityOther
Please feel free to go into more detail
Have you ever had a facial or skin treatment before?*

YesNo
If Yes, when was your last facial treatment?
What Skin Care Products do you currently use?*

Cleanser / Face WashBar SoapFace Scrub / ExfoliantsTonerSerumsMoisturizerSunscreenEye 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 usingYes, but not within the last 30 daysYes, but not within the last 6 monthsNoNot sure
Please specify which medications, product strength and length of use.
Have you received any of these hair removal services in the last 30 days?*

WaxingSugaringThreadingElectrolysis / LaserDepliatory CreamShavingBody SculptingNone
If checked, please note last time.
Have you ever received chemical peels, laser services, or microdermabrasion treatments? *

Yes, within the last monthYes, within the last 2-3 monthsNo
Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks?*

YesNo
Describe is your skin type*

OilyDryNormalCombinationDehydratedSensitive
Have you ever had a body spa or contouring treatment before?

YesNoif Yes, what kind of treatment was it
Your Health
Have you experienced any of these health conditions in the past or present?*

Hormone ImbalanceCancer / Systemic DiseaseHigh Blood PressureDiabetesHeart problemArthritisAuto-Immune DisordersAsthmaEpilepsy / Seizure DisorderFever BlistersHerpesFrequent Cold SoresHIV/AIDSLupusDepression/AnxietyHepatitisHeadaches / MigrainesOther
If you checked yes to any of these please provide further information. If not mark N/A*
Tell me about your Lifestyle. Do you?*

Wear contact lenses (remove if sensitive)Have a pacemakerHave metal implantsHave body piercingsPregnant or trying to become pregnantTanning bed/ booths (w/in last 14 days)Spend alot of time outside ( ____ Hours/ave)No, not Applicable
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 allergies?*

AspirinTree NutsCitrusLatexDairyFruitsVegetablesShellfishIodineFragrances / 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 smoker? *

YesNoSocial
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)*

YesNo
Have you ever experienced claustrophobia? *

YesNo
Please rate your stress level*

LowMediumHigh
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
Any menopause issues? *

YesNoN/A
If yes, please specify
Are you undergoing any hormone replacement therapy?

YesNo
If yes, please specify
MALE CLIENTS
What is your current shaving system? *

Razor / Wet shaveElectricN/A
Do you experience irritation from shaving? *

YesNoN/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.
Reservation & Cancellation Policy for all current and future appointments: a valid credit card is required for all appointments. Please do not foget to confirm your appointment when you receive your reminder. A $20 retainer is due at the time of booking. If you must cancel please do so at least 24 hours prior to your scheduled appointment and we will gladly transfer that fee to your next scheduled appointment. In the event of cancellations received less than 24 hours prior to appointment Tues-Fri, a cancellation fee equal to the reserved service booking will incur; Saturday cancellations require 48 hour notice. No Shows will be charged 100%*

I understand the reservation and cancellation policies at Carolina Glam Beauty Bar & Skin Spa and consent to my credit card on file being charged if I fail to give 24 hour notice for appointments scheduled Tuesday through Friday and 48 hours notice for Saturday appointments.
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*

Clear
Which of the following best describes your skin type?

Type I Fair skin tones; Always burns, never tansType II Light skin tones; Burns easily, tans slightlyType III Fair to olive skin tones; Burns/ tans moderatelyType IV Light brown skin tones; Burns slightly, tans easilyType V Dark brown skin tones; rarely burns, tans easilyType VI Dark brown to black skintones; never burns, tans easily
I understand and voluntary accept the risks associated with the facial and/or any other services, including but not limited to: Facials, Massage Techniques, Hydrodermabrasion, Nanochanneling, Facial Equipment, ETC. Or the use of any of the location’s facilities. Except where prohibited by law; I acknowledge and voluntarily assume the risk of injury, accident or death, which may arise from the use of any facial equipment, event or activity. I agree Keisha Moore of Carolina Glam, LLC will not be liable for death or any injury, including without limitation, personal, bodily or mental injury, economic loss or damage to me resulting from negligence, other acts in Carolina Glam, LLC spa, anyone acting on Carolina Glam LLC’s behalf, or anyone using the services of the facilities of Carolina Glam LLC, to the fullest extent permitted by law. This agreement, together with Carolina Glam, LLC’s wellness plan rules and regulations, constitute the entire agreement between you and us and cannot be amended, except in writing by both parties. Myself and/or any of my heirs, executors, representatives, or assignees hereby release Carolina Glam, LLC from all claims or liabilities for death, personal injury or property loss or damages of any kind sustained while on the premises, during the use of any facial equipment and/or from any advice or services provided by an employee, independent contractor or any representative of Carolina Glam, LLC. I agree that this application and waive is in effect for all facials and/or any other service, and will not expire unless specifically requested by either party. I understand that Foundation Carolina Glam, LLC is a tranquil and professional environment and that any inappropriate behavior may result in termination of my services and full payment is expect at time of service. By signing this form, I agree to the above terms and release Carolina Glam, LLC and it’s employees/owners from any liability.*

Yes
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Advance Clinical Facial

Your Skin

Your Health