New Client Consultation Form

New Client Consultation Form

*Must be 18 years older to sign consent. Minors must obtain Parent/Legal Guardian consent.
Date of Service:*

MonthDayYear
Name*

First NameLast Name
Date of Birth*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
Website / Online SearchYelpFacebookReferralOther
If Referral, please list name
If Other, please let me know
Your Skin
What are your skin care goals? *
Wrinkles / Fine LinesHyperpigmentation / Sun DamageAcne / Acne ScarringRedness / RosaceaAgingMelasmaSensitivityOther
Please feel free to go into more detail
YesNo
If Yes, when?
Cleanser / Face WashBar SoapFace Scrub / ExfoliantsTonerSerumsMoisturizerSunscreenEye Product(s)Lip Product(s)
If you are seeking corrective treatments please detail the SPECIFIC products (BRAND & PRODUCT TYPE/NAME) you are currently using so I can best answer any questions on ingredients and help you meet your skin care goals.
Cleanser / Face Wash
Bar Soap
Face Scrub / Exfoliants
Toner
Serums
Moisturizer(s)
Sunscreen
Eye Product(s)
Lip Product(s)
Yes, currently usingYes, but not within the last 30 daysYes, but not within the last 6 monthsNoNot sure
Please specify which product or type, if you answered 'Yes, currently using' to above.
WaxingSugaringThreadingElectrolysis / LaserDepliatory CreamShavingNone
If checked, please note last time.
Yes, within the last monthYes, within the last 2-3 monthsNo
YesNo
Your Health
Hormone ImbalanceCancer / Systemic DiseaseHigh Blood PressureDiabetesHeart problemArthritisAuto-Immune DisordersAsthmaEpilepsy / Seizure DisorderFever BlistersHerpesFrequent Cold SoresHIV/AIDSLupusDepression/AnxietyHepatitisHeadaches / MigrainesOtherNone
If you checked yes to any of these please provide further information. If not mark N/A*
Wear contact lensesHave a pacemakerHave metal implantsHave body piercingsNo, not Applicable
MultivitaminVitamin CVitamin D/D3ZincOmega 3 / Fish OilB Complex / B12GarlicCalciumFolic AcidMelatoninCoenzyme Q10BiotinOther
If other, please list
AspirinTree NutsLatexDairyFruitsVegetablesShellfishIodineFragrances / Essential OilsOtherNone
If Other, please specify
YesNo
If yes, please specify what and date last used
YesNoSocial
YesNo
YesNo
LowMediumHigh
Please let me know if you would like to learn about natural ways to lower stress levels
FEMALE CLIENTS
YesNoN/A
If yes, what kind
YesNoRecently had a baby and am breastfeedingN/A
YesNoN/A
If yes, please specify
YesNo
If yes, please specify
MALE CLIENTS
Razor / Wet shaveElectricN/A
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.
Late Arrival-If you arrive late we will not be able to extend your appointment time, and the result of your treatment may not be optimal.If you are 15 minutes or more late to your appointment, no services will be performed and you will have to reschedule with a non-refundable booking deposit of $50 that will be applied to your service charge. Cancellation Policy-If you are unable to make your scheduled appointment please contact us as soon as possible to reschedule. We require AT LEAST 24 hours notice.*A non-refundable booking deposit of $50 may be required to book any future appointments if you fail to comply with our 24 hour notice policy and will be applied to your service. If you fail to show or cancel that next booked appointment without a 24 hour notice your deposit will then be forfeited, and another deposit will be required for any future appointments.*

I understand the late and cancellation policies at Beauty Lux by Azures, and am fully aware failure to follow may result in a future non-refundable booking deposit.
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*
Date

MonthDayYear
Date
Should be Empty:

New Client Consultation Form

Your Skin

Your Health