Client Form

Name

First NameLast Name
Date of birth

MonthDayYear
Date
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Brief Summary Of your Skin Journey
What is your occupation? (High Stress) ?
Do you have any hobbies? (things that involve sweating, heat, chemical exposures, etc.)
Can you identify any skin triggers?
Select ALL That Apply and Interest you
Select ALL That Apply to you
Select Your Skin Type
List Main Concerns ?
What Do you Look for in a Facial ?
massage, exfoliation etc
Fluid Intake
Have you ever had a facial or Skin treatment before? Treatment
Last Treatment Date Date
Please list all products used on your face (skincare & makeup)
Brand and Company
Do you wear SPF Daily?Excessive sun exposure can cause pimples to end up as dark scars because the sun’s ultraviolet rays can increase inflammation and redness and create new breakouts Also Decreases your risk of skin cancer .
Attach CLEAR Skin Photos ( Front Face View, Side View)

Please attach minimum 2 photos, Side View or Problematic areas
Cancelof
Medical History

The medical information on this site is provided as an information resource only, and is not to be used or relied on for any diagnostic or treatment purposes. This information does not create any patient-physician relationship, and should not be used as a substitute for professional diagnosis and treatment.Please consult your health care provider before making any health care decisions or for guidance about a specific medical condition

Rows	Yes	No	If Yes,Please Specify* (Date,Name Etc)
Abdominal/Digestive problems, Hernia
Accutane ( DATE/ YEAR)
Allergies (latex, foods, aspirin, other) please list your allergies
Acne and Acne Scaring
Arthritis, Muscle/Joint Pain
Birth Control (month / year)
Blood Disorder
Botox/Fillers
Claustrophobia
Lenses
Diabetes
Fungus
Gynecological Conditions, Irregular Menstruation, etc.
Headaches/Migraines
Heart Conditions/Disease, Stroke
Herpes/Warts (genital/oral)
History of Cancer, Precancerous Lesions
History of High/Low blood pressure
History of Mental Illness, Anxiety/Depression/Fatigue
Infectious Disease (HIV, STD, etc.)
Keloid Scaring
Melasma, Hypo/Hyper Pigmentation
Metal Implants, Plates, Pins
Numbness, Loss of sensation
Phlebitis, Varicose Veins
Pregnant or Nursing
Recent Surgeries
Respiratory conditions, Asthma, Bronchitis, etc
Skin Conditions, Eczema, Psoriasis, Dermatitis, Rosacea
Skin sensitivities/Easy Bruising
Thyroid disorder
Prone To Cold Sores
Smoke (Cigarettes)
PCOS
Any FORM of Hair Removal
Do you swim in a chlorinated pool regularly?
Antibiotics

The medical information on this site is provided as an information resource only, and is not to be used or relied on for any diagnostic or treatment purposes. This information does not create any patient-physician relationship, and should not be used as a substitute for professional diagnosis and treatment.Please consult your health care provider before making any health care decisions or for guidance about a specific medical condition

Rows Yes

PLEASE LIST ALL MEDICATIONS/SUPPLEMENTS OR VITAMINS
Private Session or Do you give us permission to film and use this on social media platforms
I confirm that I have disclosed all relevant medical conditions, medications, supplements, allergies, lifestyle habits, and any other information that may affect my treatment. I understand that withholding information may increase the risk of complications.I acknowledge that the treatment, its benefits, possible risks, side effects, and alternative options have been explained to me, and I have had the opportunity to ask questions.I understand that individual results vary and that no guarantees or warranties have been made regarding the outcome of my treatment. I understand that multiple treatments and recommended home care may be necessary to achieve optimal results.I agree to follow all pre-treatment and post-treatment instructions provided by Skincare by Nicole.I understand that all treatments, treatment packages, gift certificates, and retail products are final sale and non-refundable. I also understand that Skincare by Nicole reserves the right to refuse or discontinue treatment at any time if deemed appropriate.I voluntarily consent to receive treatment and accept all associated risks, including but not limited to allergic reactions, skin irritation, bruising, swelling, pigmentation changes, infection, scarring, delayed healing, or other unforeseen complications.By signing below, I release and hold harmless Skincare by Nicole, Nicole, Meaghann, Asma, and all current and future employees, contractors, representatives, and agents from any claims, liabilities, damages, or losses arising from or related to my treatment, except where prohibited by applicable law.I certify that I have read, understood, and voluntarily agree to the terms of this Treatment Consent & Waiver.

Rows	Yes
PLEASE LIST ALL MEDICATIONS/SUPPLEMENTS OR VITAMINS

Understanding medical-grade skincare products are more potent than their over-the-counter counterparts. They contain higher concentrations of active ingredients, ensuring that they deliver noticeable results more effectively. Due to their potency, the usage frequency might differ from the usual skincare items you might find in your local drugstore. Note: Before starting your regimen, please book a 1:1 call to discuss your routine, If you have started your skin routine through me and have any concerns, please reach out. TO PURCHASE ANY ITEMS KINDLY VISIT OUR WEBSITE

Rows	AM	PM	NOTES	Recommendation (Shop: skincarebynicole.ca)
Cleanser
Targeted Cleanser
Notes for cleanser
Exfoliation
Masque
Eye cream
Toner/Mist
Serum
Serum
Serum
Notes for serum
Acne Medication
SERUM
Moisturizer
Sunscreen

Recommended Treaments
Aftercare Notes
Treatment Plan Notes
Notes Aesthetician
Notes
Check List
Recent 7-14 days
Upcoming Event, Vacation, Wedding Etc
specify date
Acne Clients Only (Complete This Section Only If Applicable)

Acne is not just a surface-level problem. It often stems from internal imbalances such as infections, stress, blood sugar dysregulation, poor digestion, deficiencies, and hormone imbalances, which require a personalized approach.
Do you drink alcohol regularly?
Have you ever been diagnosed with PCOS (Polycystic Ovary Syndrome) or suspect you might have it?
Do you eat fast food or fried foods more than twice a week?
When was the last time you had blood work done? We often recommend visiting a naturopath or integrative health practitioner to run comprehensive tests and provide guidance on diet, supplements, and lifestyle strategies that support clear skin
Do you take supplements to support gut health, immunity, or overall skin healt
Do you consume caffeine (coffee, tea, energy drinks)?
Do you have any known food sensitivities or allergies?
Do you get breakouts around your period or ovulation?
Do you experience digestive issues or food sensitivities?
Do you notice breakouts around your period or with birth control changes?
Do you regularly take prescriptions over the counter?
Do you notice breakouts after eating sugary, refined, or high-glycemic foods?
Do you consume whey or protein powders?
Do you suffer from constipation? or diarrhea?
Do you use skincare, hair, or body products that contain oils, butters, or “natural” ingredients? (ex: coconut oil, cocoa butter, shea, jojoba, argan, lanolin)
How many hours of sleep do you get on average?
Do your breakouts not respond to traditional acne trearment ( benzyol, salicylic acid etc)
Have you ever tried eliminating dairy, gluten, or sugar to see if your skin improves?
Are you taking any medications that affect hormones or skin? ex: steroids, testosterone, birth control, thyroid meds)
How often do you consume high-sugar or processed foods (soda, candy, fast food)?
Have you used antiboticis recenly ?
Do you wear makeup while working out?
Do you drink enough water daily (at least 2L or 8 cups)?
Do you take biotin?

Yes— it increase keratinization, but it also blocks the absorption of Vitamin B5 in your body.The same way biotin helps you get thicker hair and nails also causes thicker, more clumpier skin cells, which means pores are likely to get clogged and lead to acne breakouts.Also, your body needs ample amounts of B5 (pantothenic acid) to maintain clear skin. This vitamin plays a major role in your endocrine system, regulating the production of stress and reproductive hormones. Because biotin is absorbed at the same site in your intestines, it can inhibit the ability to properly utilize B5
Do you wash your face immediately after working out (within 15-30 minutes)?
What type of workouts do you typically do?
Do you wear makeup regularly and fully remove it at night?
Do you notice more breakouts during hot and humid weather?
Do you take Vitamin B12?
Should be Empty:

Acne Clients Only (Complete This Section Only If Applicable)