• Client Consultation Form

  • Format: (000) 000-0000.
  • Which of the following best describes your skin tone?*
  • What is your main skin concern? Select all that apply.*
  • Describe your skin.*
  • Do you consider you skin to be ...*
  • Are you or do you have any of the following? Select all that apply.*
  • In the last 5 days have you had any of the following? Check all that apply.*
  • In the last 2 weeks have you had any of the following? Check all that apply.*
  • In the last 3 to 4 weeks have you had a DERMAPLANE treatment? Check all that apply.*
  • In the last 3-6 months have you had any of the following? Check all that apply.*
  • Additional questions for CHEMICAL PEEL. Select all that apply
  • Additional questions for DERMAPLANE. Check all that apply.
  • Have you ever had an allergic reaction to any of the following? Check all that apply*
  • Do you have a history of autoimmune disease (such as rheumatoid arthritis, psoriasis, lupus, multiple sclerosis, etc.) or any condition that may weaken your immune system.*

  • 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 institution and/or the technician/esthetician/skin care professional from liability and assume full responsibility thereof.

  • Date*
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  • Should be Empty: