New Client Consultation Form

New Client Consultation Form
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact {Name and Phone Number}
Birthday

MonthDayYear
Date
How did you hear about us?
Occupation
Have you received a professional skin care treatment before?
What are your specific concerns at this time regarding your skin?
Preferred massage pressure?
Do you have any preferences or sensitivities with essential oils. Please explain below.
What is your number one goal for this treatment?
Medical History
Are you currently, or have you previously experienced any of the following
Do you wear contact lenses?
Do you have any metal implants, pacemaker or body piercings?
If you are currently experiencing or being treated for any health-related condition, please describe:
Have you ever had a surgical or non surgical procedure? If yes, where on your body was the surgery performed?
Do you have any allergies? Also list any skin treatment products you have used that caused an unexpected reaction or side-effect:
Please list all over-the-counter and prescription medications you are currently taking:
Please indicate if you have ever used any of the following medications for skin treatment:
What condition were you treating with this medication?
When was the last time you used these medications?
Women
Are you pregnant?
Are you planning a pregnancy in the near future?
Your Skin
What skin care products are you currently using? Please list all - cleanser, toner, serums, moisturizers, SPF
Are you interested in recommendations for a home care regimen?
Is your skin
Are you currently treating or being treated for any skin condition?
How do (or did) you treat the condition
Were you happy with the results
Have you had chemical peels, microdermabrasion or any resurfacing treatments within the last three months?
In the last 5 days have you had any waxing performed on your face?
In the last 5 days have you had any excess exposure to the sun or have been in a tanning bed?
In the last 5 days have you had any surgical/aesthetic procedures performed (i.e. botox, filler)
In the last 24 hours have you used Retin A
In the last 14 days have you been in contact with anyone who has tested positive for Covid-19 or tested positive yourself?
In the past 24 hours have you had a fever, difficulty breathing, body aches, loss of taste or smell, cough, chills, headache or sore throat?
Are you, or anyone in your household, awaiting Covid-19 results?
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**I confirm (to the best of my knowledge) that the answers I have given are correct and I have not withheld any information that may be relevant to my treatment.
Signature
Date

MonthDayYear
Date
Should be Empty:

New Client Consultation Form

Medical History

Women

Your Skin

**I confirm (to the best of my knowledge) that the answers I have given are correct and I have not withheld any information that may be relevant to my treatment.