• New Client Consultation/Consent Form

  • Date*
     - -
  •  -
  • How did you hear about me?*
  • What are your skin care challenges (check all that apply)?*
  • Scalp concerns: (Check all that apply)

  • Concerns on the body: (check all that apply)

  • Areas on the body I’d like to treat/improve: (check all that apply)

  • Do you have hair extensions?
  • 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. 
  • Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?*
  • Have you received any of these hair removal services in the last 30 days?*
  • Have you ever received chemical peels, laser services, or microdermabrasion treatments? *
  • Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks?*

  • Your Health

  • Have you experienced any of these health conditions in the past or present?*
  • Do you?*
  • Do you take any of the following dietary / health supplements?
  • Any known allergies?*
  • Have you used or been prescribed any medications (topical or oral) for acne / acne control?*
  • Are you a smoker? *
  • Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)*
  • Have you ever experienced claustrophobia? *
  • Please rate your stress level*
  • FEMALE CLIENTS
  • Are you taking birth control? *
  • Are you pregnant or trying to become pregnant?*
  • Any menopause issues? *
  • Are you undergoing any hormone replacement therapy?

  • I consent to

  • I consent to "before & after" photographs for the purpose of documentation, potential advertising, and promotional purposes.      

  • I understand that no specific guarantees of the results can or have been made and that there is the possibility I may require additional treatments/procedures to obtain the expected results at an additional cost. I understand all pre/post treatment instructions and I understand the importance of following the instructions given to me. I hereby consent to any treatments offered at Alchemy Skin (Chemical Peels, Dermaplaning, Hydrofacials, Microneedling, Waxing, DMK Enzyme Therapy, DMK Alkaline Wash, & all other treatments offered at Alchemy Skin). Although it is impossible to list every potential risk and complication, I understand that there are risks, benefits and complications associated with any/all treatments. I understand that Alchemy Skin will not be held liable for any complications, reactions, or side effects that may occur and I am agreeing to undergo all treatments provided by Alchemy Skin at my own risk.

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