New Client Consultation Form

Skin Care Consultation Form
Date *

Month Day Year
Name *

First Name Last Name
Date of Birth *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number *

Area Code Phone Number
E-mail *
How did you hear about me? *

Website / Online Search Yelp Facebook Referral Other
If Referral, please list name
If Other, please let me know
Your Skin
What are your skin care goals? *
What are your skin care challenges? *

Wrinkles / Fine Lines Hyperpigmentation / Sun Damage Acne / Acne Scarring Redness / Rosacea Aging Melasma Sensitivity Other
Please feel free to go into more detail
Have you ever had a facial or skin treatment before? *

Yes No
If Yes, when?
What Skin Care Products do you currently use? *

Cleanser / Face Wash Bar Soap Face Scrub / Exfoliants Toner Serums Moisturizer Sunscreen Eye 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)
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 No Not sure
Please specify which product or type, if you answered 'Yes, currently using' to above.
Have you received any of these hair removal services in the last 30 days? *

Waxing Sugaring Threading Electrolysis / Laser Depliatory Cream Shaving None
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 No
Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks? *

Yes No
Your Health
Have you experienced any of these health conditions in the past or present? *

Hormone Imbalance Cancer / Systemic Disease High Blood Pressure Diabetes Heart problem Arthritis Auto-Immune Disorders Asthma Epilepsy / Seizure Disorder Fever Blisters Herpes Frequent Cold Sores HIV/AIDS Lupus Depression/Anxiety Hepatitis Headaches / Migraines Other None
If you checked yes to any of these please provide further information. If not mark N/A *
Do you? *

Wear contact lenses Have a pacemaker Have metal implants Have body piercings No, not Applicable
Do you take any of the following dietary / health supplements?

Multivitamin Vitamin C Vitamin D/D3 Zinc Omega 3 / Fish Oil B Complex / B12 Garlic Calcium Folic Acid Melatonin Coenzyme Q10 Biotin Other
If other, please list
Any known allergies? *

Aspirin Tree Nuts Latex Dairy Fruits Vegetables Shellfish Iodine Fragrances / Essential Oils Other None
If Other, please specify
Have you used or been prescribed any medications (topical or oral) for acne / acne control? *

Yes No
If yes, please specify what and date last used
Are you a smoker? *

Yes No Social
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks) *

Yes No
Have you ever experienced claustrophobia? *

Yes No
Please rate your stress level *

Low Medium High
FEMALE CLIENTS
Are you taking birth control? *

Yes No N/A
If yes, what kind
Are you pregnant or trying to become pregnant? *

Yes No Recently had a baby and am breastfeeding N/A
Any menopause issues? *

Yes No N/A
If yes, please specify
Are you undergoing any hormone replacement therapy?

Yes No
If yes, please specify
Reservation & Cancellation Policy for all current and future appointments: a valid credit card is required for all appointments. Please do not forget to confirm your appointment when you receive your reminder from Vagaro. In the event of cancellations received less than 24 hours prior to appointment a charge equal to 50% of the service price will be assessed. No Shows will be charged 100% *

I understand the reservation and cancellation policies at Violet Crown Esthetics and consent to my credit card on file being charged if I fail to give 24 hour notice.
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 *

Clear
Should be Empty:

Skin Care Consultation Form

Your Skin

Your Health