Facial Consultation Form
Date
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Month
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Day
Year
Date Picker Icon
Name
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First Name
Last Name
Date of Birth
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Mobile Number
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Area Code
Phone Number
E-mail
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How did you hear about us?
Website / Online Search
Facebook
Instagram
Referral
If Referral, please list name
What are your skin care challenges?
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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?
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Yes
No
If Yes, when?
Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?
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Yes
No
Not sure
If Yes, specify which product, frequency and last time used
Have you received any of these hair removal services in the last 2 weeks?
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Waxing
Sugaring
Electrolysis / Laser
Depliatory Cream
None
If checked, please note what body area and when
Have you ever received chemical peels, laser services, or microdermabrasion treatments?
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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?
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Yes
No
Have you experienced any of these health conditions in the past or present?
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Hormone Imbalance
Cancer / Systemic Disease
Diabetes
Auto-Immune Disorders
Epilepsy / Seizure Disorder
Herpes
Frequent Cold Sores
Lupus
Hepatitis
Other
None
If you checked YES to any of these please provide further information. If not mark, NA
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Please list any current medications
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Do you?
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Wear contact lenses
Have a pacemaker
Have metal implants
Not Applicable
Any known allergies?
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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?
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Yes
No
If yes, please specify what and date last used
FEMALE CLIENTS
Are you taking birth control?
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Yes
No
N/A
If yes, what kind
Are you pregnant or trying to become pregnant?
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Yes
No
Recently had a baby and am breastfeeding
N/A
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.
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Yes
Signature
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