TheMantra Beauty Client Consultation Form

Date *

Month Day Year
Date
Name *
Date of Birth

Month Day Year
Date
Address
Home Phone
Cell Phone *
E mail address *
example@example.com
Marital Status

SIngle Married Divorced Widowed
If married, anniversary date

Month Day Year
Date
Employer
Occupation
Does your job require that you work outdoors?

No Yes
How did you hear about TheMantra Beauty? *
Business Phone
What would you like to achieve from your treatment today? *
1 Have you ever had a facial treatment before?

No Yes, when?
What was your favorite part of your last treatment?
2) Have you ever had a body spa treatment before? Massage /Salt glow /Seaweed wrap /Moor Mud Body Scrub

No Yes, specify
3 Have you ever had chemical peels, laser or microdermabrasion?

No Yes, specify
4 Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products?

No Yes, specify
5 Which of the following best describes your skin type?

Dry Oily Combination
6 Do you have any special skin problems or concerns pertaining to your face or body?

No Yes, explain
6 Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products?

Yes No If yes specify
8 Do you have any allergies, current medications or recent surgeries/procedure you would like us to know about? *

No Yes, specify
9 Have you had Botox, Restylane or Collagen injections in the past 6months? *
10 What skin care products are you currently using? List brand where known
Cleanser
Toner
Eye Cream
Day/Night Moisturizer
Sunscreen
Exfoliator/Mask/Scrub
Makeup Products
Other
11 Have you used any of the following hair removal methods in the past six weeks?

No Yes, specify
12 What areas of concern do you have regarding your: Skin: (Please check any that apply and explain)
Select all that apply *

Breakouts/acne Hyperpigmentation Uneven skin tone Scarring Blackheads/whiteheads Excessive oil/shine Rosacea Broken capillaries Uneven skin tone Sun damage Wrinkles and fine lines Dull/dry skin Flaky skin Dehydrated Sun spot/liver spot/brown spot None of the above Other, explain
Eyes

Puffiness Dark circles Dehydrated Other, specify
Lips

Cracked/chapped Dehydrated Other, specify
13 Have you ever had an allergic reaction to any of the following? (Please check any that apply and explain)

Cosmetics Fragrance Shellfish Latex Animals Other, explain
14 What SPF do you use on your face/body?
15 Have you recently used any self-tanning lotions, creams or treatments?
16 Have you had any recent tanning bed or sun exposure that changed the color of your skin?

No Yes
17 Which of the following best describes your skin?

Always burns easily, never tans Always burns, tans slightly Burns moderately, tans gradually Seldom burns, always tans well Rarely burns, deep tan Never burns, deeply pigmented
Female Clients Only
18 Are you taking oral contraceptives?
19 Any recent changes to or from your contraceptive treatment?
20 Are you pregnant or trying to become pregnant?
21 Are you lactating?
22 Any menopause problems?
23 Are you undergoing any hormone replacement therapy?
Male Clients Only:
24 What is your current shaving system?

Wet shave Electric Other, specify
25 Do you experience irritation/ingrown hairs from shaving?

No Yes, specify
Please use this space to complete answers where space was insufficient. (Please include the number of the question)
Future Appointments/Contact
May we call you at your provided phone number to confirm future appointments?

No Yes
May we contact you via mail/email about future promotions and news?

No Yes
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 TheMantra Beauty from liability and assume full responsibility thereof.
Client Signature *

Clear
Date *

Month Day Year
Date
You may upload a selfie and/or any product images that you are currently using.

Cancel of

Guest Photo/Media Release
This form seeks for the consent for photographs to be taken by the TheMantra Beauty through a therapist or a representative.

By signing this form, I affirm in understanding that the images may be used for different purposes including but not limited to;
- Educational purposes such as treatment procedure demonstration
- Social media and online publishing ads
- Print marketing advertisements
- Video and television media advertisements
By consenting to the release of images/videos, you agree that you will not receive any form of compensation.
Date

Month Day Year
Date
Signature

Clear
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Female Clients Only

Male Clients Only:

Future Appointments/Contact

Guest Photo/Media Release