New Client Consultation Form

  • Microneedling Consultation Form

  • Date*
     - -
  •  -

  • Your Skin

  • What are your skin care goals?*
  • What are your skin care challenges?*
  • Have you ever had a facial or skin treatment before?*
  • What Skin Care Products do you currently use?*
  • Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?*
  • Have you ever received chemical peels, laser services, or microdermabrasion treatments? *
  • Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks?*

  • Your Health

  • Have you experienced any of these health conditions in the past or present?*
  • Do you take any of the following dietary / health supplements?
  • Any known allergies?*
  • Have you used or been prescribed any medications (topical or oral) for acne / acne control?*
  • Are you an insulin dependant diabetic?
  • Do you have active shingles?
  • Are you haemophiliac?
  • Are you taking blood thinning medication?
  • FEMALE CLIENTS
  • Are you taking oral contraception?
  • Are you pregnant or trying to become pregnant?*
  • Are you undergoing any hormone replacement therapy?

  • Photograph and Video Release Form

  • I hereby grant and authorize The Beauty Room LLC right to take, edit, alter, copy, exhibit, publish, distribute and make use of any and all pictures, video, and/or audio taken of me to be used in and/or for any lawful promotional materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, press kits, websites, social networking sites and other print or digital communications without payment or any other consideration.This authorization extends to all languages, media, formats, and markets now known or later discovered.I waive the right to inspect or approve the finished product wherein my likeness appears, including written or electronic copy. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording.I hereby hold harmless and release The Beauty Room LLC from all liability, petitions, and causes of action which I, my heirs, representatives, executors, or any other persons may make while acting on my behalf or on behalf of my estate.Permissions granted for the pictures, video, and/or audio listed below:*

  • Treatment

  • Pre-treatment: Do not exfoliate for 24 hours. No facial treatments 7 days prior. Avoid sun exposure/burns 24 hours prior to treatment. Discontinue use of retinoids 12 hours prior. Allow 12 hours after autoimmune therapies before treatment. Wait 6 months following isotretinoin use. Wait 14 days after botox/filler treatment. After-care: Avoid direct sunlight exposure, swimming, sauna, sun beds for 7 days following the treatment. If sun exposure cannot be avoided apply Sunscreen (SPF 30+) and wear for a minimum of 7 days. No facial treatments, botox/fillers for 14 days after treatment. Keep area clean and dry for 24 hours. No heat treatments or showers for 24 hours. Do not shave face for 3 days. No perfume or aftershave for 7 days. Do not cleanse the face for 3 days Avoid alcohol for 24 hours. Drink plenty of water. Do not touch the treatment area for 6-8 hours. Change pillow cases often. Avoid sweating excessively. No ibuprofen for 24 hours. Skin may be red, slight swelling, sensitive, itchy following treatment however, this will subside significantly in 24 hours and fully heal within 5 days. Mineral makeup can be used 72 hours after treatment. Side effects: Side effects are rare however, they can occur and include Allergic reaction to steel or serums used Robust inflammation of treated area Persistent itching Cutaneous eruption Reactivation of pre-existing HSV*
  • Should be Empty: