Client Consultation Form

Client Consultation Form

Your privacy is very important. The following information is only used to assess your skin care goals, determine what treatments are appropriate for your skin condition and to avoid any possible reactions.
Full Name *

First Last
E-mail *
We will never SPAM or sell email addresses to third parties.
Phone:
ex. 555-555-5555
Birthdate:
ex. 01/05/1960
What is the best way to contact you? *

Phone call Email Text All
Who referred you to Skin Clinical?
Are you allergic to anything? *

NO YES
If yes, please list allergies:
Have you had skin cancer? *

NO YES
If yes, please list area(s):
Have you had any of these health conditions in the past or present?

Cancer Hormone imbalance Systemic disease High blood pressure Spinal injury Thyroid condition Hysterectomy Diabetes Heart problem Varicose veins Arthritis Asthma Eczema Epilepsy Fever blisters Hepatitis Herpes Cold sores Immune disorders HIV/AIDS Lupus Metal implants Phlebitis Blood clots Insomnia Seizure disorder Keloid scarring Migranes Skin disease Active Infection
Do you follow a regular exercise program? *

NO YES
After your treatment you will need to avoid working out, heavy sweating, steam rooms and/or saunas for at least 24 hours.

Walking and drinking lots of water are encouraged as they are both benefical in gently flushing the skin of cellular waste that may be released during your treatment.
Do you smoke or chew tobacco products everyday? *

NO YES
Smoking greatly reduces healing of the skin and will effect the outcome of your treatment. It is best to avoid smoking 24 hours before and after your treatment.
Do you follow a restricted diet? *

NO YES
What is your current level of stress?

Low Moderate High
List any oral MEDICATIONS you take daily:
List all oral VITAMINS or HERBS you take daily:
Do you currently use any of the following?

Retin-A Renova Adapalene Differin Glycolic Acid AHA Retinol Accutane Tazorac RoAccutane Scrubs or Peels At home laser
I understand that I must discontinue use of ALL of the above 5 days prior to treatment. Accutane or Roaccutane must be discontinued 1 year prior to treatment. *

YES, I will discontinue.
Do you currently have any rash, windburn, sensitivites or other issues on the area being treated? *

NO YES
If yes, please explain:
Do you use bleaching creams or Hydroquinone daily? *

NO YES
Does your skin form Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma? *

NO Hyper-pigment Hypo-pigment
Have you used an acne medication? *

NO YES
If yes, please list medication:
Have you had a reaction after having a facial treatment in the past? *

NO YES
Please explain the details:
Have you ever had an ALLERGIC reaction to any of the following?

AHA's Retinoid Cosmetics Medicine Food Animals / Insects Sunscreens Iodine Pollen Fragrance Shellfish Latex Topical RX NONE
Female Clients
Are you pregnant or trying to become pregnant?

NO YES
Do you have Mirena IUD, Copper IUD or other implanted birth control?

NO YES
Are you taking oral birth control?

NO YES
Brand name of birth control:
Are you lactating?

NO YES
Any current menopause problems?

NO YES
If yes, please explain:
Skin Care History
How often do you use a skin regimen? *

1x per day 2x per day I do not use a regimen
Do you feel claustrophobic during facials? *

YES NO
Do you have an aversion to hot or cold tempuratures used on your face? *

YES NO
What conditions would you like to improve? *

Acne Oily Skin Dry Skin Bumps Large Pores Melasma Redness Brown Spots Sun Damage Milia Sagging Skin Rosacea Lines & Wrinkles Healthy Aging White spots Scarring Age Management Keratosis Pilaris Hyperpigmentation Hypopigmentation
List any additional conditions you would like treated:
Current skin care products you use at home. Include brand names and product names.
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. I am aware that it is my responsibility to inform the esthetician of my current medical or health conditions and to update this history. I am aware that individual results are dependent upon my age, health condition and lifestyle. I agree to actively participate in following appointment schedules and home care procedures to the best of my ability, so that I may obtain maximum effectiveness. The treatments I receive here are voluntary and I release Forevermore SkinCare & Lashes and/or the skin care professional from liability and assume full responsibility thereof. *

I understand the cancellation policy.
To cancel an appointment please contact us at 818-922-5233 by text or call at least 24 hours prior to your appointment. Cancellations within 24 hours will be charged a fee of $50. *

I understand the cancellation policy.
OPTIONAL: I grant permission to Forevermore SkinCare & Lashes to use photos and/or video of my progress for marketing purposes on their website or other business listing pages such as Instagram.

I grant permission.
Date *

Month Day Year
Signature *
Should be Empty:

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