Skincare Consult Form
Name
*
First Name
Last 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:
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How committed are you with doing a routine?
*
Good/Bad/Okay
Age Range
*
Please Select
Under 18
18-25
25-35
35-45
45-55
55-65
65+
Budget Range:
*
How much water do you drink daily?
*
How often are you wearing SPF?
*
Never
Rarely
Sometimes
Often
Cant leave without 3 layers on
How often are you stressed out?
*
Rare
Seldom
Often
All day every day
Select all that apply:
*
Whiteheads/blackheads
Rosacea / Redness
Fine lines/wrinkles
Excess oil
Dryness / Dullness
Age spots / Hyperpigmentation
Uneven skin tone / texture
Hormonal acne
Health History
*
Allergies / Sensitivities
Major surgery within the last 120 days
Accutane within the last 120 days
Pregnant
Skin Cancer
Hepatitis
HIV
Epilepsy
Eczema
Diabetes
Psoriasis
Rashes/warts/lesions of any kind
Heart / Blood pressure conditions
Other
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)
*
Currently pregnant
Not pregnant, but trying
Not pregnant and not trying
Currently Pregnant but keep on the hush hush
I am a Male
Are you taking birth control?
Yes
No
What kind of birth control are you on?
Pill
IUD
Nexplanon
None
Ring
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?
Yes
No
How often are you drinking caffeinated drinks
*
Daily
Weekly
Monthly
Rare
How regular are your periods?
Regular
Irregular
Do you develop acne around your period?
Yes
No
Do you get cold sores? Or do you have a history of them in your family?
*
I get them, currently don't have one
I get them, currently have one
I don't get them and no one in my family does either
I don't get them and someone in my family does
Do you have to wear PPE often? (masks, gloves)
*
Everyday
Seldom
Rare
Do you drink?
*
Often
Social Drinker
Seldom
Rare
Do you smoke? (Vape, tobacco, etc )
*
Yes
No
How often do you tan?
*
Only in summer, outside
All the time
Seldom
Rare
Please upload the following:
Browse Files
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Right side view, center view, left side views of face
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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 Aesthetics
I understand and agree that I am ultimately responsible for payment in full for services received
I 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:
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