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Skin Care Consultation Form
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Today's Date
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Date
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Name
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First Name
Last Name
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Address
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Street Address
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Vietnam
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US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
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Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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4
Phone Number
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5
E-mail
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example@example.com
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6
How did you hear about me?
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Website / Online Search
Facebook
Referral
Other
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7
If Referral, please list name
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8
If Other, please let me know
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9
What are your skin care goals?
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10
Type a question
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11
What are your skin care challenges?
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Wrinkles / Fine Lines
Hyperpigmentation / Sun Damage
Acne / Acne Scarring
Redness / Rosacea
Aging
Melasma
Sensitivity
Other
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12
Besides the face, do you have any concerns in the following areas?
*
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Eyes
Neck & Decollete
Aging Hands
No other concerns
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13
Have you ever had a facial or skin treatment before?
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Yes
No
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14
If Yes, when?
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15
What Skin Care Products do you currently use?
*
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Cleanser / Face Wash
Bar Soap
Face Scrub / Exfoliants
Toner
Serums
Moisturizer
Sunscreen
Eye Product(s)
Lip Product(s)
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16
Please list the specific skin care brands and names of the skincare products you are currently using:
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17
Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?
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Yes, currently using
Yes, but not within the last 30 days
Yes, but not within the last 6 months
No
Not sure
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18
Please specify which product or type, if you answered 'Yes, currently using' to above.
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19
Have you ever received chemical peels, laser services, or microdermabrasion treatments?
*
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Yes, within the last month
Yes, within the last 2-3 months
No
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20
Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks?
*
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Yes
No
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21
Have you experienced any of these health conditions in the past or present?
*
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Hormone Imbalance
Cancer / Systemic Disease
High Blood Pressure
Diabetes
Heart problem
Arthritis
Auto-Immune Disorders
Asthma
Epilepsy / Seizure Disorder
Fever Blisters
Herpes
Frequent Cold Sores
HIV/AIDS
Lupus
Depression/Anxiety
Hepatitis
Headaches / Migraines
Other
None
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22
If you checked yes to any of these please provide further information. If not mark N/A
*
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23
Do you take any of the following dietary / health supplements?
Multivitamin
Vitamin C
Vitamin D/D3
Zinc
Omega 3 / Fish Oil
B Complex / B12
Garlic
Calcium
Folic Acid
Melatonin
Coenzyme Q10
Biotin
Other
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24
If other, please list
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25
Any known allergies?
*
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Aspirin
Tree Nuts
Latex
Dairy
Fruits
Vegetables
Shellfish
Iodine
Fragrances / Essential Oils
Other
None
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26
If Other, please specify
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27
Have you used or been prescribed any medications (topical or oral) for acne / acne control?
*
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Yes
No
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28
If yes, please specify what and date last used
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29
Are you a smoker?
*
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Yes
No
Social
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30
Do you drink more than 3 caffeinated beverages a day? (tea, coffee, soda, energy drinks)
*
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Yes
No
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31
Please rate your stress level
*
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Low
Medium
High
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32
Please let me know if you would like to learn about natural ways to lower stress levels
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33
FEMALE CLIENTS
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34
Are you taking birth control?
*
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Yes
No
N/A
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35
If yes, what kind
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36
Are you pregnant or trying to become pregnant?
*
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Yes
No
Recently had a baby and am breastfeeding
N/A
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37
Any menopause issues?
*
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Yes
No
N/A
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38
If yes, please specify
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39
Are you undergoing any hormone replacement therapy?
*
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Yes
No
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40
If yes, please specify
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41
Reservation & Cancellation Policy for all current and future appointments: a valid credit card is required for all appointments. Please do not foget to confirm your appointment when you receive your reminder from Vagaro. In the event of cancellations received less than 24 hours prior to appointment Tues-Fri, a cancellation fee equal to the reserved service booking will incur; Saturday cancellations require 48 hour notice. No Shows will be charged 100%
*
This field is required.
I understand the reservation and cancellation policies at Sacred Skincareapy and consent to my credit card on file being charged if I fail to give 24 hour notice for appointments scheduled Tuesday through Friday and 48 hours notice for Saturday appointments.
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42
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 skin care professional from liability and assume full responsibility thereof.
*
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Yes
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43
Signature
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Clear
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