New Client Consultation Form

New Client Consultation Form

The following information will be used to help plan a safe and effective treatment. Please answer the questions to the best of your knowledge. All information will remain private & confidential.
Custom FacialGlow FacialDiamond Facial
Today's Date*

MonthDayYear
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

City

Country
Phone Number*

PrefixPhone Number
E-mail*
Emergency Contact Name & Mobile
Website / Online SearchInstagramFacebookReferralOtherTiktok
If Referral, please list name
If Other, please let me know
Your Skin
What are your skin care goals? *
Wrinkles / Fine LinesHyperpigmentation / Sun DamageAcne / Acne ScarringRedness / Rosacea / SensitivityAgingBreakoutsDry / FlakyExcess OilOther
Please feel free to go into more detail
YesNo
If Yes, when?
Cleanser / Face WashBar SoapFace Scrub / ExfoliantsTonerSerumsMoisturizerSunscreenEye Product(s)Lip Product(s)
Preferred Brand(s)
Yes, currently usingYes, but not within the last 30 daysYes, but not within the last 6 monthsNoNot sure
Please specify which product or type, if you answered 'Yes, currently using' to above.
WaxingSugaringThreadingElectrolysis / LaserDepliatory CreamBotox / Dermal Fillers / Facial InjectiblesNone
If yes, please confirm last date

MonthDayYear
Date
Your Health
Hormone ImbalanceCancer / Systemic DiseaseHigh Blood PressureDiabetesHeart problemArthritisAuto-Immune DisordersAsthmaEpilepsy / Seizure DisorderFever BlistersHerpesFrequent Cold SoresHIV/AIDSLupusDepression/AnxietyHepatitisHeadaches / MigrainesCovid-19OtherNone
If you checked yes to any of these please provide further information. If not mark N/A*
Wear contact lensesWear hearing aidsNo, not Applicable
YesNo
If yes, please list
YesNo
If yes, please give details
YesNo
If yes, please give details
YesNoSocial
YesNo
YesNo
What is your daily water intake (glasses / litres)*
YesNo
LowMediumHigh
FEMALE CLIENTS
YesNoN/A
If yes, what kind
YesNoRecently had a baby and am breastfeedingN/A
YesNoN/A
If yes, please specify
YesNo
If yes, please specify
Is there any other information you would like to make your ESTHETICIAN aware of? If yes, please give details:
Post Facial Advice: Direct sunlight exposure is to be avoided immediately following the treatment (including any strong UV light exposure and/or tanning beds). If some sun exposure cannot be avoided first apply a broad spectrum sunscreen of SPF 30. Facial massage, and gua sha may cause temporary redness/pinking of the skin - this is a normal and positive outcome and indicates the increase of blood flow as a result of the treatment. If you have any concerns about this please let me know prior to the treatment. Unless otherwise specified, in the evening following your treatment, cleanse your skin with a mild cleanser and water followed by a non-active moisturizer. Do not apply exfoliating ingredients / products the day of your service as over-exfoliation can result in irritation or further sensitivity. If you have any concerns post treatment please contact me.*

I have read the post care instructions and agree to adhere to them.
I UNDERSTAND & READ the reservation and cancellation policies at URBAN GLOW aesthetics and consent to my credit card on file being charged if I fail to give the required notice.
CLIENT DECLARATION: 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. I understand that redness and other reactions may occur from facial treatments. If I experience any discomfort during the treatment I will inform the ESTHETICIAN immediately, so that the products/techniques can be adjusted. The treatments I receive here are voluntary and I release the URBAN GLOW aesthetics from liability and assume full responsibility thereof.*

YES I understand
GDPR Statement: In accordance with the General Data Protection Regulation, this information will be held securely by URBAN GLOW aesthetics for 5 years. This is standard practice and is required for insurance purposes. Please note, your personal data will remain confidential and will never be shared with a third party without your written consent. If you wish to see the data on your files, please request in writing via email to THEEURBANGLOWWAY@gmail.com Please confirm that you have read and agree with this statement.*

I agree that my information will be held securely in compliance with GDPR requirements.
Contact you about appointment and relevant follow up.Send occasional emails with news, special offers etc.
Signature*

Clear
Thank you for taking the time to complete this form - I look forward to seeing you soon. NADIJAH ✨
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New Client Consultation Form

Your Skin

Your Health