Glow Boulevard New Client Form

Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Address*

Street Address

CityState / Province

Postal / Zip Code

Email*

example@example.com

Birthday*

Date

1. What are your top three skincare concerns? (e.g., fine lines, dryness, uneven texture, breakouts)

2. Describe your dream skin in three words. (e.g., radiant, youthful, clear)

3. What are your short-term skincare goals? (e.g., achieve a dewy glow for an upcoming event, reduce redness)

4. What are your long-term skincare aspirations? (e.g., age gracefully, maintain a youthful complexion)

5. Have you experienced any significant skin changes recently? (e.g., increased sensitivity, breakouts, dryness)

6. Do you have any allergies or sensitivities to skincare ingredients? (Please list)

7. Do you have any skin concerns in any other areas other than your face?

Take Photo

1. Describe your current morning skincare routine, listing products in order of use:

2. Describe your current evening skincare routine, listing products in order of use:

3. How often do you exfoliate? What type of exfoliant do you use?

4. Do you use any facial tools or devices in your routine? (e.g., jade roller, gua sha, LED mask)

5. How much water do you drink daily?

6. Describe your typical diet. Be sure to mention: *What types of foods do you eat regularly? *Do you have any dietary restrictions? *Do you consume caffeine or alcohol? If so, how often?**

7. How would you describe your stress levels?

8. What do you do for stress management? (e.g., exercise, meditation, spending time in nature)

9. How many hours of sleep do you get on average?

10. *Do you have any sleep challenges? (e.g., difficulty falling asleep, waking up during the night)

Please provide a list of all the skincare products you currently use, including brand and product name.

Have you been under the care of a dermatologist within the past year. If so, what for?*

Do you currently use Accutane, Retin-A, or any other prescription skincare products? Please specify.*

Do you have any skin diseases/disorders that have been diagnosed by a doctor? Please specify.*

Have you received chemical peels, microdermabrasion, dermaplaning, or any other resurfacing treatments? Please specify treatment and how long ago.*

Do you have any allergies or sensitivities? Please specify.*

Are you pregnant, lactating, or trying to become pregnant? Please specify.*

List any medications you take regularly.*

List any skin treatments, waxing, etc. that you receive regularly.*

List any dietary restrictions.*

Do you play sports or workout regularly?*

YesNo

Do you wear makeup regularly?*

YesNo

How would you describe your skin type? Check all that apply.*

Dry - may look dull or feel tight, while severe dryness can cause the skin to crack, flake, or peel. dry skin and dehydrated skin are sometimes used interchangeably, but they’re not the same thing. dehydration is a lack of water, and that can happen to anyone, regardless of skin type. dry skin results from a lack of oil in the skin. This is often due to genetics but can be worsened by internal and external factors.Combination - skin that displays two or more defining characteristics—like dryness and oiliness—in different areas. oftentimes, people with combination skin will have an oilier T-zone (forehead, nose, and chin), while their cheeks will be drier.Oily - skin is characterized by a higher-than-average production of sebum, skin’s natural oil. This excess oiliness can make the skin appear shiny or greasy and is often accompanied by skin concerns like blackheads and enlarged pores. As clogged pores are a major contributor to breakouts, those with oily skin may also be prone to breakouts.Sensitive - while sensitive skin isn’t technically a skin type, your skin can be any skin type and experience sensitivity. just because your skin is characterized as sensitive now does not mean it will always be! sensitive skin is characterized by a heightened sensitivity to stressors, including some skincare products. degrees of sensitivity can vary: some people only experience mild irritation when exposed to stressors, while others struggle with redness, itching, and discomfort regularly. That being said, sensitivity isn’t always visible—sometimes, it’s just about how the skin feels.Normal - while we would argue that all skin is normal, in skincare, normal refers specifically to skin that’s well-balanced and displays no persistent skin concerns.

Do you tan regularly indoors or outdoors?

IndoorOutdoorNo

Do you wear sunscreen regularly? (Not included in makeup)*

YesNo

How did you hear about Glow Boulevard, Self Care Studio?*

I give my esthetician and Glow Boulevard, Self Care Studio permission to take photo and/or video of me during my service to use for promotional and educational purposes, as well as to keep track of my progress between treatments.

I agree.

If I experience any pain or discomfort during the session I will immediately inform Roree Green so that the session may be adjusted to my level of comfort. I further understand that aesthetic treatments should not be considered a substitute for medical examination, diagnosis, or treatment, and that I should see a physician or other qualified medical specialist for any mental or physical alignment that I am aware of. I understand that licensed estheticians are not qualified to diagnose, prescribe, or treat any physical or mental illness, and nothing in the course of the session should be constructed as such. Because certain aesthetic treatments should not be performed under certain medical conditions, I affirm that I have stated all my non-medical conditions and answered all questions honestly. I agree to keep Glow Boulevard, Self Care Studio and Roree Green updated as to any changes in medical profile, and I understand that there shall be no liability on Glow Boulevard, Self Care Studio or Roree Green as I should fail to do so.*

I agree.

Signature*

Date*

Date

Consultation Form

Welcome!

Step 1: Unveiling Your Skin Story

Step 2: A Glimpse into Your Skin's Essence

Step 3: Your Current Skincare & Wellness Ritual

Step 4: Your Skincare Collection

Step 5: Additional Modality Questions

Step 5: Your Bespoke Skincare Prescription

Throughout the Year:

I'm excited to partner with you on this transformative skincare journey!