New Client Consultation Form

1
Name* This field is required.
First Name
Last Name
2
Date* This field is required.
Date
Month
Day
Year
3
Phone Number* This field is required.
Area Code
Phone Number
4
E-mail* This field is required.
example@example.com
5
What are your skin care goals?* This field is required.
6
What are your skin care challenges?* This field is required.
Wrinkles / Fine Lines
Hyperpigmentation / Sun Damage
Acne / Acne Scarring
Redness / Rosacea
Aging
Melasma
Sensitivity
Other
7
Please feel free to go into more detail
8
Have you ever had a facial or skin treatment before?* This field is required.
Yes
No
9
If Yes, when?
10
What Skin Care Products do you currently use?* This field is required.
Cleanser / Face Wash
Bar Soap
Face Scrub / Exfoliants
Toner
Serums
Moisturizer
Sunscreen
Eye Product(s)
Lip Product(s)
11
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.
12
Cleanser / Face Wash
13
Bar Soap
14
Face Scrub / Exfoliants
15
Toner
16
Serums
17
Moisturizer(s)
18
Sunscreen
19
Eye Product(s)
20
Lip Product(s)
21
Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?* This field is required.
Yes, currently using
Yes, but not within the last 30 days
Yes, but not within the last 6 months
No
Not sure
22
Please specify which product or type, if you answered 'Yes, currently using' to above.
23
Have you received any of these hair removal services in the last 30 days?* This field is required.
Waxing
Sugaring
Threading
Electrolysis / Laser
Depliatory Cream
Shaving
None
24
If checked, please note last time.
25
Have you ever received chemical peels, laser services, or microdermabrasion treatments?* This field is required.
Yes, within the last month
Yes, within the last 2-3 months
No
26
Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks?* This field is required.
Yes
No
27
Have you experienced any of these health conditions in the past or present?* This field is required.
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
28
If you checked yes to any of these please provide further information. If not mark N/A* This field is required.
29
Do you?* This field is required.
Wear contact lenses
Have a pacemaker
Have metal implants
Have body piercings
No, not Applicable
30
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
31
If other, please list
32
Any known allergies?* This field is required.
Aspirin
Tree Nuts
Latex
Dairy
Fruits
Vegetables
Shellfish
Iodine
Fragrances / Essential Oils
Other
None
33
If Other, please specify
34
Have you used or been prescribed any medications (topical or oral) for acne / acne control?* This field is required.
Yes
No
35
If yes, please specify what and date last used
36
Are you a smoker?* This field is required.
Yes
No
Social
37
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)* This field is required.
Yes
No
38
Have you ever experienced claustrophobia? * This field is required.
Yes
No
39
Please rate your stress level* This field is required.
Low
Medium
High
40
Please let me know if you would like to learn about natural ways to lower stress levels
41
FEMALE CLIENTS
42
Are you taking birth control?* This field is required.
Yes
No
N/A
43
If yes, what kind
44
Are you pregnant or trying to become pregnant?* This field is required.
Yes
No
Recently had a baby and am breastfeeding
N/A
45
Any menopause issues?* This field is required.
Yes
No
N/A
46
If yes, please specify
47
Are you undergoing any hormone replacement therapy?
Yes
No
48
If yes, please specify
49
MALE CLIENTS
50
What is your current shaving system?* This field is required.
Razor / Wet shave
Electric
N/A
51
Do you experience irritation from shaving?* This field is required.
Yes
No
N/A
52
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.* This field is required.
Yes
53
Signature* This field is required.
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