Skincare Consult Form

Name*

First NameLast Name

Email*

example@example.com

What are your specific skin goals?*

What is your skincare routine? (Morning/Night, brands, extras, LIST EVERYTHING)*

Easier to just upload a picture of your routine, add here:

How committed are you with doing a routine?*

Good/Bad/Okay

Age Range*

Budget Range:*

How much water do you drink daily?*

How often are you wearing SPF?*

How often are you stressed out?*

RareSeldomOftenAll day every day

Select all that apply:*

Health History*

Specify what you're allergic to:

Any medications you're taking? Skin medications you tried? What were you treating?

Do you have any plates/screws/replacement joints?

Are you pregnant or looking to get pregnant? (Please be honest, I have to ensure I use proper products on you)*

Are you taking birth control?

YesNo

What kind of birth control are you on?

What is your diet like? Fast food? Supplements? Eating habits? Diets you've tried? *

List everything you can

Are you interested in getting on a supplement routine to help your skin from the inside out?

YesNo

How often are you drinking caffeinated drinks*

DailyWeeklyMonthlyRare

How regular are your periods?

RegularIrregular

Do you develop acne around your period?

YesNo

Do you get cold sores? Or do you have a history of them in your family?*

I get them, currently don't have oneI get them, currently have oneI don't get them and no one in my family does eitherI don't get them and someone in my family does

Do you have to wear PPE often? (masks, gloves)*

EverydaySeldomRare

Do you drink?*

OftenSocial DrinkerSeldomRare

Do you smoke? (Vape, tobacco, etc )*

YesNo

How often do you tan?*

Only in summer, outsideAll the timeSeldomRare

Please upload the following:

Right side view, center view, left side views of face

Please agree to the following terms and conditions*

I hereby agree to have a facial done by a skincare professional, and/or may be asked to purchase at-home products to continuously help with skin concerns.I understand and agree to follow after care steps. I understand that incorrect or lack of after care may results in damage to the skin, and I agree to take on that risk.I understand that even with a patch test there is still a potential for an allergic reaction & I agree to take on that risk.I understand that by signing this form it acts as proof of consent for today at Savvy Skin AestheticsI understand and agree that I am ultimately responsible for payment in full for services receivedI understand that if I have a medical condition or symptoms of facial/bodywork may be contraindicated. A referral from my primary care doctor may be required prior to services being provided. I understand that the facial/bodywork services I receive are for relaxation and skincare initiatives. If I receive any pain or discomfort during my session(s) that I will tell my aesthetician right away. Further, I understand that facial/bodywork is not a medical examination, diagnosis, or treatment and that I should see my qualified physician for any physical or mental illness. I affirm that I have stated every medical condition and answered every question honestly. I understand that services should not be provided to those with medical conditions. It is understood that any disrespectful, sexual or racist remarks will not be tolerated and will result in immediate termination of that session, as a client in general, and will have to pay the session in full. I understand that the service(s) I sought out +purchased do involve some risk of injury and I elect to participate in these services voluntarily, despite risk involved. I agree to indemnify and hold harmless the practitioner, subsidiaries, affiliates, directors, owners, representatives, volunteers, and any other agents, waving liability and indemnification provisions contained therein.

If person is under the age of 18,

Type option 1

SAVANNAH'S NOTES: