New Client Consultation Form
Date Picker Icon
Date of Birth
Street Address Line 2
District of Columbia
How did you hear about us?
Website / Online Search
If Referral, please list name
If Other, please let us know
What are your skin care goals?
What are your skin care challenges?
Wrinkles / Fine Lines
Hyperpigmentation / Sun Damage
Acne / Acne Scarring
Redness / Rosacea
Please feel free to go into more detail
Have you ever had a facial or skin treatment before?
If Yes, when?
What Skin Care Products do you currently use?
Cleanser / Face Wash
Face Scrub / Exfoliants
Please list out the brand/brands you are currently using for your skincare routine.
Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives? (please keep in mind, if you have used ANY from of retinol in the last 7 days, you will not be able to get any facial service/chemical peel.)
Yes, currently using
Yes, but not within the last 30 days
Yes, but not within the last 6 months
Please specify which product or type, if you answered 'Yes, currently using' to above.
Have you received any of these hair removal services in the last 30 days? (please keep in mind, if you have received any of the services in the last 7 days, you will not be able to get any facial service/chemical peel.)
Electrolysis / Laser
If checked, please note last time.
Have you ever received chemical peels, laser services, or microdermabrasion treatments?
Yes, within the last month
Yes, within the last 2-3 months
Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks? (please keep in mind, if you have received any of the services in the last 14 days, you will not be able to get any facial service/chemical peel.)
Have you experienced any of these health conditions in the past or present?
Cancer / Systemic Disease
High Blood Pressure
Epilepsy / Seizure Disorder
Frequent Cold Sores
Headaches / Migraines
If you checked YES to any of these please provide further information. If not mark, NA
Wear contact lenses
Have a pacemaker
Have metal implants
Have body piercings
Do you take any of the following dietary / health supplements?
Omega 3 / Fish Oil
B Complex / B12
If other, please list
Any known allergies?
Fragrances / Essential Oils
If Other, please specify
Have you used or been prescribed any medications (topical or oral) for acne / acne control?
If yes, please specify what and date last used
Are you a smoker?
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)
Have you ever experienced claustrophobia?
Please rate your stress level
Are you taking birth control?
If yes, what kind
Are you pregnant or trying to become pregnant?
Recently had a baby and am breastfeeding
When was your last period?
Any menopause issues?
If yes, please specify
Are you undergoing any hormone replacement therapy?
If yes, please specify
Post Facial Care/Waxing/Chemical Peel Instructions: Aerobic exercise and/or vigorous physical activity should be avoided for 48 hours. Direct sunlight exposure is to be avoided immediately following the treatment (including any strong UV light exposure and/or tanning beds). If some sun exposure cannot be avoided first apply a broad spectrum sunscreen of SPF 30. Sunscreen (with a minimum SPF 15) should become part of your daily skin care regimen as skin can potentially become more sensitize to the sun as a result of this treatment. Unless otherwise specified, in the evening following your treatment, cleanse your skin with a mild cleanser and water followed by a non-active moisturizer. Do not apply additional exfoliating ingredients/products the day of your service as over-exfoliation can result in irritation or further sensitivity. Consult your skin care professional before resuming topical treatments. Enzyme peels, chemical peels or facial waxing can result in skin flushing/redness or slight skin flaking or sensitivity for up to 48-72 hours post treatment. DO NOT peel, pick, rub, or scratch your skin at any time, whatsoever this can potentially cause damage or compromise your results. Do NOT workout for 3 days after your chemical peel. Limit going in the sun after your chemical peel treatment. Make sure to apply sunscreen, use sun protection, and follow pre and post chemical peel instructions. Do not exfoliate and mask for 7 days after chemical peel. A chemical peel will NOT be preformed on pregnant or breastfeeding women.
I have read the post care instructions and agree to adhere to them.
Cancellation policy: In failure to cancel your appointment before the 24 hour mark will result in a $50 charge. No shows will also be charged $50
I understand the reservation and cancellation policies at Noellesthetics by Noelle Bucsa.
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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