New Client Consultation Form

Name* This field is required.

First Name

Last Name

Todays Date* This field is required.

Date

Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Email* This field is required.

example@example.com

Confirm Email

Phone Number

Please enter a valid phone number.

Have you seen a Dermatologist in the past year?.

YESNO

Reason for visiting Dermatologist:.

New or Returning Client?* This field is required.

New

Returning

Please check all that apply

Metals

Nuts

Citrus

Vitamin C

Vitamin A

Retinol

Benzoyl Peroxide

Salicylic Acid

Aspirin

Sulfur / Eggs

Shellfish

Fish

Chemical Peels

Cosmetics

Herbs, Vegetation

Flowers

Airborne Particles

Other

If Other, please explain.

Do you wear SPF/Sunscreen?* This field is required.

YESNO

Tell us which brand of Sun Protection you are using if any.

Please Select Your Natural Skin Tone

Always burns, never tans

Burns easily, tans minimally

Sometimes burns, slowly tans to light brown

Burns minimally, always tans to moderate brown

Resistant skin, rarely burns, tans well

Very resistant skin, never burns, deeply pigmented

Please Select Your Skin Type

Normal

Combination

Dry/Dehydrated

Oily

Sensitive

Please Select Your Main Skin Concern* This field is required.

Acne

Anti-Aging

Hyperpigmentation

General Skincare

Please Choose Your Severity (acne)

Minimal

Minimal to Moderate

Moderate to Severe

Severe

Do you pick, pop, scratch or rub at lesions?

YESNO

How long have you suffered from acne?

Please detail all products / medications you currently use to treat your acne

On a scale of 1 to 10 how serious are you about clearing your acne?1 being not serious at all - 10 being very serious

Please choose your severity (antiaging)

Minimal Fine Lines

Minimal to Noticeable Fine Lines and Wrinkles

Noticeable Increasing Lines and Wrinkles

Visible Lines/Wrinkles

Please detail all products / treatments you are using and have had to address your antiaging needs.Also include what you liked/disliked about them.

Please Select Your Severity

Mild

Mild to Moderate

Moderate

Severe

Please Select All That Apply

Pigment occurred after acne

Pigment occured during pregnancy

Pigment is less than 1 year old

Pigment is older than 5 years old

Pigment occurs with pimples

Pigment occurs with scratches

Pigment occured after sunburn

Pigment occurred after skincare treatment

Pigment worsens in summer season

Pigment occurs after hair removal

Pigment is mixed with acne

Pigment is mixed with Keloids

Please detail all products / treatments you are using and have had to address the hyperpigmentation. Also include what you liked/disliked about them.

Please tell us what types of skincare treatments or assistance you are most interested in receiving.* This field is required.

Please let us know all products you are currently using as part of your skincare routine - (brand and type of products.)

Please list all Medications (prescribed and over the counter) and Supplements you are taking.

Please select as many medical conditions you have now or in have had in the past – All information provided remains confidential and is used only to provide the safest aesthetic care minus risk of contraindications.

Asthma

Arthritis

Aspirin (Daily Dose)

Blood Thinners

Cancer

Chemotherapy

Covid-19

Stroke

Heart Condition

Headaches/Migraines

Hormonal Issues

Diabetes

Hypoglycemia

Cold Sores/Fever Blisters

Herpes

Hepatitis

PCOS

HIV/AIDS

Circulatory Issues

Vision Difficulties

Hearing Difficulties

High Blood Pressure

Lupus

Thyroid

Blood Clots

Breathing/Respiratory Issues

Fainting

Muskoskeletal or Neurological Issues

Infectious skin disease

Pregnant

Metal Implants

Other

If Other, Please Explain

Have you had aesthetic treatments before, and if so what. Also let us know if you had any complications or unsatisfactory results.

Tell us what you wish for your complexion goals with the assistance of your Aesthetician.

PHOTO UPLOAD: Not required for in-office appointments. When uploading a photo of your skin, it should be in natural light, no filters, makeup and front view, and side views.This is required for virtual Tele-Aesthetic and Contactless Consultations

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

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Do you have anything you would like to add?

I understand, 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 this document is to provide the best possible guest experience when visiting or receiving Tele-Aesthetic professional care from Crystal Clarity Skincare* This field is required.

Yes

Keep in touch with us by telling us your social media links - we would love to follow you!

Your Website (if applicable)

Please verify that you are human* This field is required.

New Client Consultation Form