Client Consultation

Name:   First Name   Last Name   
   
Date of Birth:   Date   

Address:   Street Address   Address Line 2   City   State   Zip   

Phone:      

Marriage status:    Single    Married  
 
Employer:     Occupation:      


Does your job require that you work outdoors?:    No    Yes   

Referred by:      

What would you like to achieve from your treatment today?      

1) Have you ever had a facial treatment before? No   Yes   when?      

2) Have you ever had a facial treatment before?   No   Yes   when?      
Massage   
Salt glow 
Seaweed wrap   
Body Scrub 
Facial    
      
    Other:      

3) Which of the following best describes your skin type? (Please circle one type number)
Creamy complexion Always burns easily, never tans   
Light Complexion Always burns, tans slightly    Light/Matte Complexion Burns moderately, tans gradually    Matte Complexion Seldom burns, always tans well   
Brown Complexion Rarely burns, deep tan    Black Complexion Never burns, deeply pigmented      

4) Do you have any special skin problems or concerns pertaining to your face or body?    No   Yes   
   Specify:      
   In the last month?      No   Yes   

6) Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products?
No  Yes         
Describe:      

7) Have you used any of these products in the last 3 months?    No   Yes   

8) Have you used an acne medication?    No   Yes When?      
Which drug? 

9) Which skincare brands are you currently using? (List brands where known)      
    Cleanser                   
Type a label    Toner   
Type a label    Eye Products   
Type a label    Serums       
Type a label    Exfoliator  
Type a label    Scrubs    
Type a label    Shower Gels/Body Products
Type a label    Body Lotions   
Type a label    Sunscreen on Body
Type a label    SPF       
Type a label    Night Moisturizer/Cream  
Type a label    Makeup Products   
Type a label    Others   
10) Have you recently used any self-tanning lotions, creams or treatments   No   Yes         
Specify:      

11) Have you used any of the following hair removal methods in the past six weeks?   No   Yes   Check all that apply:
Shaving    Waxing    Electrolysis    Plucking    Tweezing    Stringing    Depilatories    Laser Hair Removal       


12) What areas of concern do you have regarding your:
Skin
Breakouts/acne     Blackheads/whiteheads           Rosacea     Redness/ruddiness     Sun spot/liver spot/brown spot     Breakouts/acne     Blackheads/whiteheads     Excessive oil/shine     Rosacea     Broken capillaries     Redness/ruddiness     Sun spot/liver spot/brown spot     Other  

Eyes:
Dehydrated     Wrinkles        Puffiness     Dark circles        Other:      

Lips:
Dehydrated     Cracked/chapped lips           Other         


13) Have you ever had an allergic reaction to any of the following? (Please check any that apply and explain)
If yes, please explain:       
Cosmetics    Medicine    Food    Animals    Sunscreens    Iodine    Pollen    AHAs   Fragrance    Shellfish    Latex    Drugs    Other        


14) What SPF do you use on your face?      How often/when?      

15) What SPF do you use on your body?      How often/when?      

16) Have you had any recent tanning bed or sun exposure that changed the color of your skin?   No   Yes   
specify:      
17) Have you experienced Botox, Fillers, Restylane, or Collagen Injections?       Yes    No      
If yes, please specify: Type a label   
18) Are you currently taking any medications? If yes, please specify:   Type a label   


Female Clients Only:
18) Are you taking oral contraceptives?   No   Yes   
specify:      

19) Any recent changes to or from your contraceptive treatment?   No   Yes   
if so, what and when:      

20) Are you pregnant or trying to become pregnant?    No   Yes   

21) Are you lactating?   No   Yes   

22) Any menopause problems?   No   Yes   
specify:      

23) Are you undergoing any hormone replacement therapy?   No   Yes   
specify:      

Male Client Only:
24) What is your current shaving system?   Wet shave   Electric   

25) Do you experience irritation from shaving?   No   Yes   Ingrown hairs?   No   Yes   


CONTRAINDICATIONS FOR FACIAL SERVICES:

1) USE OF ACCUTANE IN THE LAST YEAR WITHOUT DOCTOR'S NOTE
2) PREGNANCY/NURSING FOR CERTAIN SERVICES
3) HISTORY OF SKIN CANCER WITHOUT DOCTORS NOTE
4) FACIAL WAXING 7-14 DAYS PRIOR TO FACIAL SERVICE
5) BOTOX/FILLERS 7-14 DAYS PRIOR TO FACIAL SERVICE
6) NO PEELS/MICRODERMABRASION ON ANY CLIENT WITH DIABETES/AUTO IMMUNE DISEASES/CANCER
7) NO LED THERAPY ON CLIENTS WITH EPILEPSY
8) ACTIVE COLD SORES/RASHES/OPEN WOUNDS

**A $50 DEPOSIT IS REQUIRED TO BOOK ALL FACIAL APPOINTMENTS**

*WE MUST HAVE A CARD ON FILE FOR EACH CLIENT*

DEPOSITS WILL BE CHARGED TO THE CLIENT AND NON REFDUNDABLE IF THE APPOINTMENT IS CANCELED WITHOUT A 24 HOUR NOTICE TO THE APPOINTMENT TIME, OR IF CLIENT FAILS TO SHOW FOR THE APPOINTMENT

Future Appointments/Contact
May I call you at your home, work or cell phone number to confirm future appointments?   No   Yes   

May I contact you via mail/email about future promotions and news?   No   Yes   

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 institution and/or skin care professional from liability and assume full responsibility thereof

Cilent Signature:   Signature   Date  : Date