New Client Consultation Form

New Client Consultation Form
Date*

MonthDayYear
Name*

First NameLast Name
Date of Birth*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
Website / Online SearchYelpFacebookReferralOther
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 / RosaceaAgingMelasmaSensitivityOther
Please feel free to go into more detail
YesNo
If Yes, when?
Cleanser / Face WashBar SoapFace Scrub / ExfoliantsTonerSerumsMoisturizerSunscreenEye Product(s)Lip Product(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 CreamShavingNone
If checked, please note last time.
Yes, within the last monthYes, within the last 2-3 monthsNo
YesNo
Your Health
Wear contact lensesHave a pacemakerHave metal implantsHave body piercingsNo, not Applicable
MultivitaminVitamin CVitamin D/D3ZincOmega 3 / Fish OilB Complex / B12GarlicCalciumFolic AcidMelatoninCoenzyme Q10BiotinOther
If other, please list
AspirinTree NutsLatexDairyFruitsVegetablesShellfishIodineFragrances / Essential OilsOtherNone
If Other, please specify
YesNo
If yes, please specify what and date last used
YesNo
YesNo
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
MALE CLIENTS
Razor / Wet shaveElectricN/A
YesNoN/A
Post - Advanced Skincare or loaser/Spray tan/Waxing Instructions: Aerobic exercise and/or vigorous physical activity should be avoided for 24-48 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 30. Sunscreen (with a minimum SPF 15) 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 gentle 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 care professional before resuming topical treatments. Advanced skincare treatments, laser treatments, chemical peels or 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.
Remedi Wellness & Spa has a 24-hour cancellation policy. If you do not contact us to cancel your reservation within 24 hours or do not show for your scheduled treatments, Remedi reserves the right to charge your credit card 50% of the scheduled treatments. I understand the reservation and cancellation policies at Remedi Wellness and Spa.
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*

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New Client Consultation Form

Your Skin

Your Health