Client Consultation
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Name
First Name
Last Name
Phone Number
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Area Code
Phone Number
Email
example@example.com
How did you hear about me?
What would you like to achieve from your treatment today?
YOUR SKIN
1) Have you ever had a facial treatment before?
Do you have any special skin problems or concerns pertaining to your face? If yes, please specify
Have you ever had chemical peels, laser or microdermabrasion? If yes, please specify when
Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products? If yes, please describe
Have you used any of the previously listed products in the last 3 months?
Have you used an acne medication?
When was the last time you used acne medication?
What acne medication have you used?
Current Skincare Routine (please list)
Please be specific
Cleanser
Toner
AM Moisturizer
PM Moisturizer
SPF
Eye Cream
Serum
Mask
Have you recently used any self-tanning lotions, creams or treatments?
Have you used any hair removal methods in the past six weeks? If yes, please list
Area of Concern - SKIN:
Breakouts/ Acne
Blackheads/ Whiteheads
Excessive Oil/ Shine
Rosacea
Broken Capillaries
Redness/ Ruddiness
Sun Spot/ Liver Spot/ Brown Spot
Uneven Skintone
Sun Damage
Wrinkles/ Fine Lines
Dull/ Dry Skin
Flaky Skin
Dehydrated Skin
Other
Areas of Concern - EYES:
Dehydrated
Wrinkles
Puffiness
Dark Circles
Other
Areas of Concern - LIPS:
Dehydrated
Dry/ Cracked Lips
Wrinkles/ Fine Lines
Have you ever had an allergic reaction to any of the following?
Cosmetics
Medicine
Food
Animals
Sunscreens
Pollen
Alpha Hydroxy Acids
Fragrance
Shellfish
Latex
Drugs
Other
If Other, please list:
Please detail severity of any allergies
What SPF do you use on your face?
How often? When?
Have you had any recent tanning bed or sun exposure that changed the color of your skin?
Do you spend extended periods of time exposed to the sun on a regular basis?
Have you experienced Botox, Restylane or Collagen injections?
Are you taking oral contraceptives?
Any recent changes to or from your contraceptive treatment?
Are you pregnant or trying to become pregnant?
Are you lactating?
Are you undergoing any hormone replacement therapy?
Signature
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previ- ous 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 institution and/or skin care profes- sional from liability and assume full responsibility thereof.
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