Client Consultation Form
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Status
*
Please Select
Single
Dating
Engaged
Married
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
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5
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31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
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1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
About your skin
What is your skin type?
*
Oily
Combination
Dry
Other
What are your concerns?
*
Anti-aging
Texture
Hyperpigmentation
Acne / breakouts
Sensitivity
Other
How does your skin heal?
*
Quickly
Slowly
Prone to scar
Prone to pigmentation
Do you have any of the following conditions? Or N/A
*
Cancer
Hypotension
Pacemaker or Defibrillator
Claustrophobia
Thyroid Disorder
Hormonal Imbalance
Hepatitis A/B/C
Depression/Anxiety
Rosacea
Bruise Easily
Immune Disorder
Keloid Scarring
Skin Disease
Menopause
Varicose Veins
Hypertension
Metal Implants
Diabetes
Heart Disease
Hysterectomy
Epilepsy or Seizures
HIV AIDS
Migraines/Headaches
Psoriasis
Eczema
Spinal Cord Injury
Lupus
Blood Clot Disorder
Fibromyalgia
Circulation Disorder
N/A
Other / Specify
What is your reasoning for visiting today?
*
Have you ever experienced any of the following?
*
Rosacea
Dermatitis
Skin cancer
Broken capillaries
N/A
Do you consider your skin to be sensitive? (redness, stinging, itching or dryness?)
*
Yes
No
If you answered yes, when do you experience these symptoms?
*
Always (year round)
Occasionally (seasonal)
Infrequently (it has occurred but not often)
N/A
When exposed to the sun do you...
*
Always burn, never tan
Always burn, sometimes tan
Sometimes burn, sometimes tan
Never burn, always tan
Do you have any dietary restrictions / preferences? (Ex: Gluten free, Keto diet, etc) Or N/A
*
Have you had any surgeries in the last 90 days? If yes, please select "other" and specify
*
No
Other
Homecare
Select the skincare products that you currently use at home
*
Pre cleanse / makeup remover
Cleanser
Toner
Vitamin C
Serum
Exfoliant / scrub
Mask
Lip balm
Eye cream
Moisturizer
SPF
List the skincare product line(s) or N/A
*
Please select what reflects your daily makeup routine
*
Primer
Tinted moisturizer / Tinted SPF
Foundation
Concealer
Cream bronzer
Cream highlighter
Cream blush
Powder bronzer
Powder highlighter
Powder blush
Setting powder
Eyeshadow
Eyeliner
Mascara
Lip liner / Lipstick
Setting spray
Other
List the makeup product line(s) or N/A
*
If you are seeking corrective treatments please detail the SPECIFIC products (BRAND & PRODUCT TYPE/NAME) you are currently using so I can best answer any questions on ingredients and help you meet your skin care goals.
Have you had direct sun exposure in the last 14 days?
*
Yes
No
Do you sunbathe OR participate in regular outdoor activities?
*
Yes
No
Do you use a tanning bed?
*
Yes
No
If yes, have you tanned in the last 14 days?
*
Yes
No
Do any of your products contain the following?
*
Benzoyl Peroxide
Glycolic Acid
Lactic Acid
Salicylic Acid
Retinol
Rescorcinol
Hydroquinone
I'm not sure
Other
Have you ever received a professional skincare treatment?
*
Yes
No
If yes, what type of treatment? or N/A
*
When was your last treatment? or N/A
*
Wellness
Please rate your average level of stress
*
Not stressed
1
2
3
4
Very stressed
5
1 is Not stressed, 5 is Very stressed
Please check any of the following that are applicable to you
*
Contact lenses
Stroke
High cholesterol
Asthma
Cold sores / herpes simplex
Braces / permanent retainer
Irregular heartbeat
Anemia
Tobacco use
Facial piercing(s)
Heart attack
High / low blood pressure
None of the above
Other
Are you allergic to any of the following
*
Aspirin / Salicylates
Citrus
Latex
Milk
Grapes
Marine or plant life
Fish
None of the above
List any allergies or N/A
*
Have you experienced any of the following in the last 14 days?
*
Facial surgery
Collagen injections
Light treatments (LED or IPL)
Chemical peel
Microdermabrasion
Dermaplane
Microneedling
Microblading
Permanent make up
None of the above
Please list any oral medications and/or topical creams prescribed by a doctor or dermatologist or N/A
*
Are you currently taking medication for depression or anxiety? Ifso please list below or N/A
*
Please select your current form of birth control or N/A
*
Pill
IUD
Depo shot
Arm implant
Natural cycles
Nuva ring
N/A
Other
How long have you been using birth control? Or N/A
*
0-3 months
4-6 months
7-12 months
1-4 years
5+ years
N/A
Do you specifically take any of the following supplements?
*
Vitamin B12
Vitamin B6
Vitamin D
Zinc
Ashwaganda
Collagen
N/A
Please list any vitamins and/or supplements taken regularly or N/A
*
Have you received botox or filler in the last 3 months?
*
Botox
Filler (lips, cheek, chin, etc)
Neither
Please select all that apply to you
*
Pregnant
Trying to conceive
Currently nursing
Recently miscarried
None of the above
Additional
Who referred you to Keilee Esthetics?
First Name
Last Name
How did you find Keilee Esthetics?
*
Friend / Family member (please mention above!)
Instagram
Facebook
Tiktok
Google
Other
Can Keilee Esthetics take / use any photos or videos for educational and promotional content purposes on social media platforms (instagram, facebook, tiktok, email promotions, etc)? *This is certainly not a requirement to book, I just like to ask beforehand!*
*
Yes, I give my consent to Keilee Esthetics
No, I withhold my consent
Is there anything not included in this consultation form that you believe Keilee Esthetics needs to know about your skin prior to your appointment? or N/A
*
Understanding
I understand that...
*
I will not participate in light workout activity until 24 hours after my appointment. If I choose to participate, I understand it could have negative effects on my skin.
I understand that...
*
I will not participate in heavy workout activity until 48 hours after my appointment. If I choose to participate, I understand it could have negative effects on my skin.
I understand that...
*
I will not participate in any outside skin treatments (not approved by Keilee Esthetics) preformed by myself or another professional for at least 3 weeks after my appointment. If I choose to participate, I understand it could have negative effects on my skin.
I understand that...
*
I will not participate in any direct, unprotected sun exposure after my appointment. If I choose to participate, I understand it could have negative effects on my skin.
I understand that...
*
I will not participate in any alcohol consumption or smoking of any kind for 3 days after my appointment. If I choose to participate, I understand it could have negative effects on my skin.
Signature
*
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