Digital Esthetics Consultation Form
Please provide your personal information below. Thank you!
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AM/PM Option
Full Name
*
Please type first and last name.
D.O.B. (MM/DD/YYYY)
*
Phone (DAYTIME)
*
Phone (EVENING)
Email Address
*
example@example.com
Occupation
How did you hear about us?
Conditions you are currently experiencing today (Please select all that apply):
Headache
Inflammation
Muscle Cramps
Anxiety
Fatigue
Insomnia
Stress
Forgetfulness
Which aroma(s) do you prefer? (Please select all that apply)
Lavender
Citrus
Geranium
Peppermint
Lemongrass
Patchouli
Eucalyptus
Frankincense
What is your at home skincare routine?
Esthetics Information
What type of skin do you have?
Normal
Oily
Dry
Combination
Have you been under the care of a dermatologist within the past year?
*
YES
NO
If yes, please explain...
What areas of concern do you have regarding your skin?
Breakouts/Acne
Blackheads/Whiteheads
Uneven Skin Tone
Sun Damage
Excessive Oil/Shine
Wrinkles/Fine Lines
Dull/Dry Skin
Rosacea
Broken Capillaries
Redness/Ruddiness
Dehydrated
Sun, Liver, Brown Spots
Other
Have you ever had an allergic reaction to any of the following?
Cosmetics
Medicine
Food
Animals
Sunscreen
Drugs
Iodine
Pollen
AHAs
Fragrance
Shellfish
Latex
Do you currently or have you used in the last 3 months Retin-A, Renova, AHA's, or Retinol/Vitamin A derivative products?
*
YES
NO
If yes, please describe...
Have you received Botox, Restylane, or Collagen injections in the last 6 months?
*
YES
NO
If yes, please specify...
Client Signature
*
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