Advance Clinical Facial
client consultation form
Date Picker Icon
Date Picker Icon
Date of Birth (mm/dd)
Street Address Line 2
State / Province
Postal / Zip Code
Antigua and Barbuda
Bosnia and Herzegovina
Central African Republic
Cocos (Keeling) Islands
Democratic Republic of the Congo
Turkish Republic of Northern Cyprus
Papua New Guinea
Republic of the Congo
Saint Kitts and Nevis
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Sao Tome and Principe
Trinidad and Tobago
Tristan da Cunha
Turks and Caicos Islands
United Arab Emirates
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
How did you hear about me?
Website / Online Search
If Referral, please list name
If Other, please let me know
Which services are you having done?
brow services (tint, wax, henna, lamination)
weight management services (cavidation, laser lipo, RF, sauna wrap)
What are your skin care goals?
What is your skin condition or concerns? (check all that apply)
Wrinkles / Fine Lines
Hyperpigmentation / Uneven Skin Tone
Excessive Oil/ Shine
Dull/ Dry Skin
Redness / Rosacea
Comodones (Blackheads/ Whiteheads)
Dehydrated/ Lacking Moisture
Aging/ Fine Lines/ Wrinkles
Please feel free to go into more detail
Have you ever had a facial or skin treatment before?
If Yes, when was your last facial treatment?
What Skin Care Products do you currently use?
Cleanser / Face Wash
Face Scrub / Exfoliants
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
Please specify which medications, product strength and length of use.
Have you received any of these hair removal services in the last 30 days?
Electrolysis / Laser
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
Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks?
Describe is your skin type
Have you ever had a body spa or contouring treatment before?
if Yes, what kind of treatment was it
Have you experienced any of these health conditions in the past or present?
Cancer / Systemic Disease
High Blood Pressure
Epilepsy / Seizure Disorder
Frequent Cold Sores
Headaches / Migraines
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 pacemaker
Have metal implants
Have body piercings
Pregnant or trying to become pregnant
Tanning 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?
Omega 3 / Fish Oil
B Complex / B12
If other, please list
Any known allergies?
Fragrances / Essential Oils
If Other, please specify
Have you used or been prescribed any medications (topical or oral) for acne / acne control?
If yes, please specify what and date last used
Are you a smoker?
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)
Have you ever experienced claustrophobia?
Please rate your stress level
Are you taking birth control?
If yes, what kind
Are you pregnant or trying to become pregnant?
Recently had a baby and am breastfeeding
Any menopause issues?
If yes, please specify
Are you undergoing any hormone replacement therapy?
If yes, please specify
What is your current shaving system?
Razor / Wet shave
Do you experience irritation from shaving?
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 & Makeup Studio 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.
Which of the following best describes your skin type?
Type I Fair skin tones; Always burns, never tans
Type II Light skin tones; Burns easily, tans slightly
Type III Fair to olive skin tones; Burns/ tans moderately
Type IV Light brown skin tones; Burns slightly, tans easily
Type V Dark brown skin tones; rarely burns, tans easily
Type 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, Microdermabrasion, 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 Foundation Skincare By Michelle, 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.
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