Facial Consultation Form

NAME

DATE of BIRTH

Date

EMAIL

example@example.com

PHONE

SEX

Female Male Other

What is your preferred pronoun?

Have you ever had a facial treatment before? YES/NO If yes, please specify when and what treatment:

Have you ever had chemicals peels, laser treatments, or microdermabrasion? YES/NO if yes, in the last month?

What is your occupation? Does your work require you to work outdoors? YES/NO

What would you like to achieve from your treatment today?

Which of the following best describes your skin type? Please check one

Type I Fair skin tones—Always burns, never tans Type 2 Light skin tones—Burns easily, tans slightly Type 3 Fair to olive skin tones—Burns moderately, tans moderately Type 4 Light brown skin tones—Burns slightly, tans easily Type 5 Dark brown to black skin tones—Never burns, tans easily

Do you use Accutane, Retin-A, Renova, Adapalene Hydroxyl Acid or any other Retinol/vitamin A derivative products? YES/NO if yes, please specify what and when last used:

Have you used acne medication? YES/NO If yes, please specify what medication and last used

Do you have any special skin problems or concerns pertaining to your face or body? if yes, please specify

What skincare products are you currently using? (List brands if known)

Have you had/used any hair removal methods in the last 6 weeks? ex) shaving, tweezing, wax/sugar, electrolysis, depilatories, other:

Do you experience irritation from shaving? YES/NO

Do you experience ingrown hairs as a result of hair removal? YES/NO

What areas of concern do you have regarding your: Skin (check all that apply)

Have you ever had an allergic reaction to any of the following (check all that apply)

What SPF do you use on your face? when/how often?

Have you recently used any self-tanning lotions, creams or treatments? if yes, please speficy:

Have you had any recent tanning bed or sun exposure that changed the color of your skin? YES/NO If yes, please specify:

Are you taking any oral contraceptives? YES/NO if yes, please specify:

Have you experienced any recent changes to or from your contraceptives? YES/NO if yes, please specify:

Are you pregnant or trying to become pregnant? YES/NO

Are you experiencing any menopausal symptoms? YES/NO

Are you currently undergoing any hormone therapy treatments? YES/NO if yes please specify:

How many glasses of water do you drink per day?

How many caffeinated beverages (coffee, tea, soda, etc.) do you consume per day?

How many alcoholic beverages do you consume per week?

How many hours of sleep do you get per night?

Which foods do you consume on a regular basis? FRUITS, FISH, VEGETABLES, GRAINS/BREAD, DAIRY/EGGS, PROCESSED SUGAR, CHEESE, PROCESSED MEATS, POULTRY..

In average, how many hours do you spend in front of a screen or digital device?

Do you exercise on a regular basis? YES/NO

Do you smoke cigarettes, vape, or consume other tobacco products? YES/NO

What are your stress levels on a scale from 1 to 5 (1 = low stress, 5 = high stress)?

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 institution and/or the technician/esthetician/skin care professional from liability and assume full responsibility thereof.

I am located in Downtown Petaluma inside the Prince building. Street parking & a parking garage is near by Petaluma market (FREE)

LATE POLICY

10mins late = $5 fee or your appt can be cancelled depending on the appt itself.

15 mins late = your appointment can be canceled and a no-show fee will be applied if you wish to reschedule.

*At this time, cash and card only. No more apps.

IF YOU WOULD LIKE TO ADD AN ADDITIONAL SERVICE (or to remove a service if booked multiple ones) PLEASE MESSAGE ME AS SOON AS POSSIBLE SO I CAN TRY TO ACCOMMODATE YOUR NEEDS 707.782.6979

1) NO EXTRA GUESTS

2) Text me once before coming upstairs and I'll give you the okay to come in.

3) NO MASK NO LOVE

CANCELATION & RESCHEDULING POLICIES

Cancellations/rescheduling accepted up to 24 hours before the scheduled service.

Cancellations/rescheduling with less than 24-hours will be charged 50% of the scheduled cost.

No-calls/no-shows & day-of cancellations will be charged 100% of the scheduled service.

You have a 10 minute grace period, if you are later than that, your appointment can be CANCELED and you will be charged 100% of the scheduled service before being allowed to reschedule a new service.

***NEW Late cancellations/reschedules due to that time of the month will be equal to $40 fee. Yes, I am able to perform the service even during that time of the month so please plan ahead when booking your maintenance Brazilian. I recommend taking a shower if possible, wearing a clean fresh tampon and taking Advil if feeling anxious.

While I make every effort to make my customers as happy as possible, all service sales/products are final.

Unfortunately I cannot offer refunds on any used or unused services, service packages, gift cards.

IF YOU WOULD LIKE TO ADD AN ADDITIONAL SERVICE PLEASE MESSAGE ME AS SOON AS POSSIBLE SO I CAN TRY TO ACCOMMODATE YOUR NEEDS 707.782.6979

Client Name (Printed)

Client Name (Signature)

Date

Facial Consultation Form

YOUR SKIN CARE

HEALTH HISTORY

LIFESTYLE