Skincare Client 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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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone number
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E-mail
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Your Skin
What are your skin care goals?
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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 and what skin treatment did you have?
What Skin Care Products do you currently use?
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Cleanser / Face Wash
Bar Soap
Face Scrub / Exfoliants
Toner
Serums
Moisturizer
Sunscreen
Eye Product(s)
Lip Product(s)
Mask
Other
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, currently using
Yes, but not within the last 30 days
Yes, but not within the last 6 months
No
Not sure
Please specify which product or type, if you answered 'Yes, currently using' to above.
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
Your Health
Have you experienced any of these health conditions in the past or present?
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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
If you checked yes to any of these please provide further information. If not mark N/A
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Do you?
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Wear contact lenses
Have a pacemaker
Have metal implants
Have body piercings
No, not Applicable
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
If other, please list
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
Are you a smoker?
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Yes
No
Social
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)
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Yes
No
Have you ever experienced claustrophobia?
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Yes
No
Please rate your stress level
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Low
Medium
High
Please let me know if you would like to learn about natural ways to lower stress levels
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
Any menopause issues?
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Yes
No
N/A
If yes, please specify
MALE CLIENTS
What is your current shaving system?
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Razor / Wet shave
Electric
N/A
Do you experience irritation from shaving?
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Yes
No
N/A
Post Facial Treatment Instructions: Aerobic exercise and/or 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. Fruit peels and microdermabrasion 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.
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I have read the post care instructions and agree to adhere to them.
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.
Yes
Signature
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