New Client Consultation
Street Address Line 2
State / Province
Postal / Zip Code
How did you hear about us?
Mr. and Ms. Day Spa
Face Reality Website
If Referral, please list name
Please list all skincare products + brands you are currently using and be specific.
Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives
Yes, currently using
Yes, but not within the last 30 days
Yes, but not within the last 60 days
Have you ever received chemical peels, laser services, or microdermabrasion treatments
Yes, within the last month
Yes, within the last 2-3 months
Yes, but not within the last 60 days
Have you received any of these facial hair removal services within the last 7 days?
If checked, please note last time
Have you received Botox in the last two weeks?
Have you received any Fillers in the last 30 days?
Have you ever experienced any of these health conditions in the past or present?
Cancer / Systemic Disease
High Blood Pressure
Epilepsy / Seizure Disorder
Frequent Cold Sores
Depression / Anxiety
Headaches / Migraines
Wear contact lenses
Have a pacemaker
Have metal implants
Have body piercings
No, not applicable
Please list ALL prescribed and over the counter meds (including vitamins/supplements) you are currently taking.
What would you like to improve about your skin? Please list any known skin conditions or skin concerns.
Please list all known allergies
Are you a chronic skin picker?
Do you smoke tobacco or cannabis?
Yes to both
Do you drink more than 4 caffeinated beverages per day? (tea, coffee, soda, energy drinks, etc)
How much water do you drink per day?
Around 60 fl. oz or less
Around 90 fl. oz
Around 120 fl. oz
1 Gallon+ per day
Please rate your stress level
Are you taking birth control?
If yes, what kind?
Are you pregnant or breastfeeding?
Yes, I am pregnant
Yes, I am breastfeeding
No to both or N/A
I consent to pictures and/or videos being taken of my face during the facial, which may be posted on the @skinwithrobin business instagram page.
Yes, you have my permission
Maybe, I'd like to approve the images first
No, I do no consent
Post Facial Care Instructions: Aerobic exercise and/or vigorous physical activity should be avoided for 48 hours. Direct sunlight exposure is to be avoided immediately following treatment. If some sun exposure is unavoidable, apply a broad spectrum sunscreen of SPF 30+ every two hours. Enzyme peels and chemical peels can result in skin flushing/redness, slight skin flaking or sensitivity for up to 48-72 hours post treatment. DO NOT peel, pick, or rub, or scratch your skin at any time. This can potentially cause damage and compromise your results.
I have read the post-care instructions above and agree to adhere to the them.
Post Facial Reservation & Cancellation Policy for all current and future appointments: a valid credit card is required to hold an appointment and will remain on file. The card will not be charged for your service until after your appointment, so you can choose a different method of payment at that time. If you fail to cancel or reschedule your appointment with at least 24 hours notice, you will be charged 100% of the service(s) booked for late cancellations. If you do not show up for your appointment, you will be charged 100% of the service(s) booked. If you are late to your appointment, that time will be deducted from your service and you will be charged 100% of the service(s) booked.
I understand the reservation and cancellation policies at Skin with Robin and consent to my credit card on file being charged if I fail to meet the required cancellation policies.
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclose, 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 (Robin Pettus) and all Skin with Robin employees, from liability and assume full responsibility thereof.
Yes, I assume full responsibility
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