FACIAL CONSULTATION
MEDICAL HISTORY
HEART CONDITION
CANCER
HERPES
PACEMAKER
CLAUSTROPHOBIC
ECZEMA
PSORIASIS
HEMOGLOBIN
STAPH INFECTION
THYROID ISSUES
METAL IN BODY
HIV/AIDS
ANXIETY
Other
If you are currently being treated for any health conditions, please describe:
Do you have any allergies? (SULFUR, LATEX, ASPIRIN) Also list any skin products/ingredient that you have experienced a reaction/side effect?
Are you sensitive to any specific scent? (Lavender, Citrus, etc)
Please indicate if you have ever used any of the following medications for a skin treatment?
Accutane
Benzoyl Peroxide
Retinol/Retin A/Retinaldehyde
Tretinoin
Clindamycin
Differin
Spironolactone
When was the last time you used this medication?
Are you currently pregnant or breastfeeding?
Are you currently taking any vitamins/supplements?
Are you currently on any type of hormonal therapy? If so, please describe.
Do you have a hormonal imbalance that you know of?
What skincare products are you currently using? Please list. (Be descriptive- ex: Glymed Plus Mega Purifying Cleanser)
Are you wearing a daily sunscreen? If so, what kind?
Do you swim in chlorinated pools?
YES
NO
What are your skin concerns? What would you like to focus on during your appointment?
If experiencing acne- does it start inflamed/non-inflamed? Can you see or feel small skin colored bumps?
Are you a picker?
How often are you changing your pillowcase you sleep on?
How often do you wear makeup/what do you apply with?
Do you use any type of LED light therapy?
Any history of long term use of antibiotics?
Do you use drying sheets or wool balls?
Would you describe your skin to be: Oily, Normal, Combination, Dry, Acne prone?
Have you seen a Dermatologist or Esthetician for your skin concerns? If so, are you currently being treated?
What do you do for work? Do you work around excessive heat or cold?
What is your current stress level? Are you stressed about your skin?
Around how many hours of sleep do you typically get?
Do you currently use a tanning bed?
Do you sweat regularly? Sauna, steam, hot yoga?
How much water do you drink daily?
How much caffeine do you have daily?
Please indicate any of the following that apply to your eating habits?
Fast Food
Salt/Salty Snacks
Peanuts/Peanut Butter (H)
Nut Butters (H)
Dairy (H)
Cow Milk (H)
Whey Powder, Whey/Soy Protein (H)
Oily foods (H)
Seed Oil (soybean, canola, peanut, sunflower, safflower, grapeseed)
Seafood
Spicy Food (I)
Egg Yolk (H)
Red Meat (H)
Tomatoes(I)
Red Wine (I)
Refined Sugar (I)
Gluten (I)
Oats/ Oatmilk
Sushi
Kelp/Miso Soup/ Seaweed
Client's Name
First Name
Last Name
How did you hear about skinbycarlyn?
Email Address
example@example.com
Do you consent to a dermplane, chemical peel, or nano needle add on if decided?
Are you interested in adding or adjusting your skincare routine and need advice?
Are you looking to be a consistent client (monthly/ bimonthly)?
Are you okay with photos being taken for content/ Being posted on Instagram?
Cancellation Policy
If you are feeling sick in the slightest bit, I ask you to please cancel your appointment and reschedule for another date. If you cannot make your scheduled appointment, please notify me 48 hours beforehand. If you fail to do so, I will charge 50% of your service fee. If you cancel day of, I will charge 100% of your service fee. I appreciate clear communication and expect a message if you are running late. I allow a ten minute window of being late or we will need to reschedule and you will be charged.
I have read and agree to the policies and would still like to book an appointment
YES
NO
Client's Signature
Date Signed
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Month
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Day
Year
Date
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