Client Consultation

Date:   Date   

Name:   First Name   Last Name   

Address:   Street Address   Address Line 2   City   State   Zip   

Phone:      

Marriage status:   Single   Married  
 
Employer:     Occupation:      

Does your job require that you work outdorors?:   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   
Moor mud  
Body Scrub               
    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:      

5) Do you have any special skin problems or concerns pertaining to your face or body? 
No   
Yes   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? 
Soap                   
Toner Mask   
Eye Product   
Cleanser Day Moisturizer  
Exfoliator  
Scrubs   
Shower Gels
Body Lotions   
Sunscreen
SPF    
Night Moisturizer/Cream  
Makeup Products   
Others   

9) What skin care products are you currently using? (List brand where known)
   

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   , circle all that apply
Shaving   Waxing   Electrolysis   Plckuing   Tweezing   Stringing   Depilatories         


12) What areas of concern do you have regarding your
Skin
Breakouts/acne    Blackheads/whiteheads       Excessive oil/shine    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 had any recent tanning bed or sun exposure that changed the color of your skin?   No   Yes   
specify:      

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   

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   

ATTENTION

Per our spa policy: Groupon / Vouchers will only be honored for NEW customers only. if we match a groupon/voucher price for a customer once, we will NOT accept any other groupon. We appreciate the support from all our clients. Thank you!