New Client Consultation Form

Client Consultation Form
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
May we text you on the number provided?*

YesNo
E-mail*
What is your preferred method of contact? (Text/Call/E-Mail)*
What is your secondary method of contact? (Text/Call/E-Mail)*
How were you referred to me?
Occupation:*
Your Skin
What would you like to achieve from your treatment today?*
How committed are you to reaching your skincare goals? Are you willing to follow proper homecare?

Yes, I am going to stick with my daily homecareNo, I am just here to treat myself once in a whileMaybe, I will try but make no promises
What are your skin care goals? *
Please choose your skin TYPE*

DryOilyNormalCombination
Which of the following best describes your skin type?*

Type I Fair skin tones-Always burns, never tansType II Light skin tones-Burns easily, tans slightlyType III Fair to olive skin tones-Burns moderately, tans moderatelyType IV Light brown skin tones-Burns slightly, tans easilyType V Dark brown skin tones-Rarely burns, tans easilyType VI Dark brown to black skin tones-Never burns, tans easily
What are your skin care challenges?*

Aging / Sagging SkinBlackheads / WhiteheadsBreakouts / Acne / Acne ScarringDehydrated SkinDull / Dry SkinExcessive Oil / ShineWrinkles / Fine LinesHyperpigmentation / Sun DamageMelasmaRedness / RosaceaSensitivitySun / Liver / Brown SpotsUneven Skin ToneOther
Have you ever had a facial or skin treatment before?*

YesNo
If Yes, when?
Describe your skincare routine. What skincare products do you currently use?

Please detail the SPECIFIC products (BRAND & PRODUCT TYPE/NAME) you are currently using and indicate if you use it AM or PM.
Cleanser / Face Wash
Face Scrub / Exfoliants
Toner
Serums
Moisturizer(s)
Sunscreen
Eye Product(s)
Lip Product(s)
Do you/have you used Retin-A, Renova, Adapalene Hydroxyl Acid, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?*

Yes, currently usingYes, but not within the last 30 daysYes, but not within the last 6 monthsYes, but over a year agoNoNot sure
Please specify which product or type, if you answered 'Yes, currently using' to above.
Have you used or been prescribed any medications (topical or oral) for acne / acne control?*

YesNo
If yes, please specify what and date last used
Have you ever received chemical peels, laser services, or microdermabrasion treatments? *

Yes, within the last monthYes, within the last 2-3 monthsYes, over 6 months agoNo
Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks?*

YesNo
Have you received any of these hair removal services in the last 7 days?*

WaxingSugaringThreadingElectrolysis / LaserDepliatory CreamShavingNone
Your Health & Lifestyle
Do you have any known allergies?*

AspirinTree NutsLatexDairyFruitsVegetablesShellfishIodineFragrances / Essential OilsNoneOther
Have you experienced any of these health conditions in the past or present?*

Hormone / Thyroid ImbalanceCancer / Systemic DiseaseHigh Blood PressureDiabetesHeart problemArthritisAuto-Immune DisordersAsthmaEpilepsy / Seizure DisorderFever BlistersHerpesFrequent Cold SoresHIV/AIDSLupusDepression/AnxietyHepatitisHeadaches / MigrainesNoneOther
If you checked yes to any of these please provide further information.*
Do any of the following apply to you?*

Wear contact lensesHave a pacemakerHave metal implantsHave body piercingsNo, not applicable
Do you take any of the following dietary / health supplements?*

MultivitaminVitamin CVitamin D/D3ZincOmega 3 / Fish OilB Complex / B12GarlicCalciumFolic AcidMelatoninCoenzyme Q10BiotinNoneOther
If other, please list
Do you smoke cigarettes, vape or consume other tobacco products?*

YesNoSocial
Do you use tanning beds or go tanning outdoors?*

YesNo
If yes, how often? When was the last time?*
How many alcoholic beverages do you consume per week?*

I don't drink1-3 drinks4-7 drinks8+ drinks
How many glasses of water do you drink per day?*

< 1 glass1-3 glasses4-7 glasses8+ glasses
How many caffeinated beverages do you consume per day? (tea, coffee, soda, energy drinks)*

None1-2 drinks3-5 drinks6+ drinks
How many hours of sleep do you get per night?

< 3 hours3-5 hours6-8 hours8-10 hours10+ hours
Do you exercise on a regular basis?

YesNo
Please rate your stress level

LowMediumHigh
Have you ever experienced claustrophobia? *

YesNo
What is your preferred pressure for massage?*

LightMediumFirmI would prefer to not have a massage
FEMALE CLIENTS
Are you taking birth control?

YesNoN/A
If yes, what kind
Are you pregnant or trying to become pregnant?

YesNoRecently had a baby and am breastfeedingN/A
Any menopause issues?

YesNoN/A
If yes, please specify
Are you undergoing any hormone replacement therapy?

YesNo
If yes, please specify
MALE CLIENTS
Do you experience irritation/ingrowns from shaving?*

YesNoN/A
What is your current shaving system? *

Razor / Wet shave / ElectricWaxingN/AOther
Post Facial Care/Sugaring Instructions: Aerobic exercise and/or vigorous physical activity should be avoided for a minimum of 24 hours. Direct sunlight exposure is to be avoided immediately following ANY treatment (including any strong UV light exposure and/or tanning beds). If some sun exposure cannot be avoided first apply a broad spectrum sunscreen of SPF 30+. Sunscreen (with a minimum SPF 30) should become part of your daily skin care regimen as skin can potentially become more sensitize to the sun as a result of this treatment. Unless otherwise specified, in the evening following your treatment, cleanse your skin with a mild cleanser and water followed by a non-active moisturizer. Do not apply additional exfoliating ingredients/products the day of your service as over-exfoliation can result in irritation or further sensitivity. Consult your skin care professional before resuming topical treatments. Enzyme peels, Microdermabrasion treatments, chemical peels or sugaring hair removal can result in skin flushing/redness or slight skin flaking or sensitivity for up to 48-72 hours post treatment. DO NOT peel, pick, rub, or scratch your skin at any time, whatsoever. This can potentially cause damage or compromise your results. Those receiving a chemical peel must purchase and follow the home care as instructed.*

I have read the post care instructions and agree to adhere to them.
Before/After photos are needed for ALL client files in case of adverse reactions and may be used for social media purposes. I consent to “before-and-after” photographs for the purpose of documentation, potential advertising, and promotional purposes.*

Yes, you may use my photos for advertising and promotional purposes.Yes, but for the purpose of my treatment file only.
Reservation & Cancellation Policy for all current and future appointments: a valid credit card is required for all appointments. Please confirm your appointment when you receive your reminder. In the event of cancellations received less than 24 hours prior to appointment, 50% of the reserved service booking will be charged as a cancellation fee. No shows will be charged 100% cancellation fee.*

I understand the reservation and cancellation policies and consent to my credit card on file being charged if I fail to give 24 hour notice for appointments or if I no show my appointment.
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, 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 from liability and assume full responsibility thereof.*

Yes
Signature*

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Client Consultation Form

Your Skin

Your Health & Lifestyle