New Client Consultation Form

1
Name* This field is required.
First Name
Last Name
2
Date* This field is required.
Date
Month
Day
Year
3
When was your last facial?* This field is required.
Please Select
Please Select
a month ago
few months ago
year or years ago
this is my first facial
4
Are you currently
Pregnant
breast feeding
taking Birth Control
have any injuries
Botox fillers
taking Glycolic
AHA/BHA
Retin-A
Retinol
Adapalene
Accutane
Differin
Mandelic Acid
have cold sores
menopause
sunburnt
smoking
have cancer or systemic disease
high blood pressure
diabetes
arthritis
epilepsy/seizure disorder
asthma
herpes or hepatitis
lupus
claustrophobia
depressed
have anxiety
migraines
wear contacts
using skin thinning products
5
Allergies?
6
Medication or vitamins:
7
Best Described Skin Type
sensitive
dehydrated
itchy eyes
rosacea
flaking
fine lines/wrinkles
oily t-zone
oily all over
open pores
whiteheads
blackheads
pustules
broken capillaries
freckles
underlying congestion
age or sun spots
easily burned
hyperpigmentation
dark circles around eyes
tired eyes
facial hair
dull
eczema
psoriasis
8
What are your skin care goals?
9
Expectations for today's treatment?
10
I drink water cups of water and caffeine cups of caffeinated drinks per day.
11
Do you exfoliate?
yes
no
sometimes
12
Had chemical peel, laser or microdermabrasion before?
yes
no
13
Is Todays service including a Microdermabrasion or peel ?
yes
no
14
I knowingly and willingly consent to having skin care service(s) during the COVID-19 pandemic.* This field is required.
by checking this box I understand and accept this statement.
15
I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it, and who does not give the current limits in virus testing.* This field is required.
by checking this box I understand and accept this statement.
16
I confirm that I have or have not traveled domestically within the United States by commercial airline, bus or train within the past 14 days* This field is required.
YES
NO
17
I verify that I have not traveled outside the United States In the past 14 days to countries that have been affected by COVID-19* This field is required.
YES
NO
18
I have read and filled out the information above. If I have any concerns I will address these to my therapist immediately. I give my therapist permission to perform any facial treatments and will hold her and her staff harmless from any liability that may result from treatments. I also, to my best knowledge, given any accurate account of my medical history, including all known allergies or prescription drugs or products I'm currently ingesting or using topically. I understand my skin therapist will take every precaution to minimize or eliminate any negative reaction as much as possible. I agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosures. I understand that this document is to provide the best possible guest experience when receiving any treatment from the therapist signed below.* This field is required.
by checking this box I understand and accept this statement.
by checking this box I understand and accept treatment to recieve Facial/Microdermabrasion/peel/waxing services
19
Signature* This field is required.
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