New Client Consultation Form

Date*

MonthDayYear

Name*

First NameLast Name

Phone Number*

Area CodePhone Number

E-mail*

What are your skin goals and objectives? *

What are your skin care challenges?*

Please feel free to go into more detail

Have you ever had a facial or skin treatment before?*

YesNo

If Yes, when?

What Skin Care Products do you currently use?*

Please detail the SPECIFIC products (BRAND & PRODUCT TYPE/NAME) you are currently using so we can best answer any questions on ingredients and help you meet your skin goals.

Cleanser / Face Wash

Soap

Face Scrub / Exfoliants

Toner

Serums

Moisturiser(s)

Sunscreen

Eye Product(s)

Lip Product(s)

Masks or Treatment

Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?*

Please specify which product or type, if you answered 'Yes, currently using' to above

Have you ever received chemical peels, laser services, or microdermabrasion treatments? *

Yes, within the last monthYes, within the last 2-3 monthsNo

Have you received any of these services in the last 30 days?*

If yes, please specify

Have you experienced any of these health conditions in the past or present?*

If you checked yes to any of these please provide further information. If not mark N/A*

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?*

YesNo

If yes, please specify what and date last used

Are you a smoker? *

YesNoSocial

Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)*

YesNo

Have you ever experienced claustrophobia? *

YesNo

WOMEN CLIENTS

Are you pregnant or trying to become pregnant?*

YesNoRecently had a baby and am breastfeedingN/A

Any menopause issues? *

YesNoN/A

If yes, please specify

Are you undergoing any hormone replacement therapy?

YesNo

If yes, please specify

MALE CLIENTS

What is your current shaving system? *

Razor / Wet shaveElectricN/A

Do you experience irritation from shaving?

YesNoN/A

Post Treatment Care Instructions: Aerobic exercise and/or vigorous physical activity should be avoided for 48 hours. 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 or higher should become part of your daily skin care regimen as skin can potentially become more sensitize to the sun as a result of this 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 additional exfoliating ingredients/products the day of your service as over-exfoliation can result in irritation or further sensitivity. Consult your skin therapist before resuming topical treatments. Chemical peels or facial waxing can result in skin flushing/redness or slight skin flaking or sensitivity for up to 48-72 hours post treatment. DO NOT peel, pick, rub, or scratch your skin at any time, whatsoever. This can potentially cause damage or compromise your results.

I have read the post care instructions and agree to adhere to them*

Yes

Do we have your permission to take/post photos on our social media platforms?

Cancellation Policy*

Reservation and Cancellation policy for all current and future appointments : A credit card must be used to secure your appointment. You will not be charged until you complete your service. You will be charged a late cancellation fee 50% of the service(s) booked if failure to cancel or reschedule your appointment within 24 hours.

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.

Yes

Signature*

New Client Consultation Form

Your Skin

Your Health