Client Consultation

Client Consultation

On The Glow Skincare Studio
Name

First NameLast Name
D.O.B

MonthDayYear
Phone Number
Have you ever had a facial treatment before?
Are you currently using any prescription medications as in Retin-A, Accutane, prescriptive creams or meds for the skin?
Have you ever received Botox or Fillers ? if so, when and what part of the face?
Have you ever received chemical peels, laser services, facial waxing ? If so, when?
What are your skin concerns ? For example: Acne, hyperpigmentation, dryness, fine line/ wrinkles.....
DO YOU HAVE ANY KNOWN ALLERGIES? IF SO, PLEASE LIST THEM BELOW
ARE YOU CURRENTLY PREGNANT OR BREASTFEEDING?
HAVE YOU HAD ANY ISSUES WITH LAYING FLAT ?
ARE YOU EXPERIENCING ANY HEALTH CONDITIONS, SUCH AS DIABETES, HIGH BLOOD PRESSURE, HEART PROBLEMS OR OTHER ? PLEASE NAME THEM BELOW
PLEASE CONFIRM THAT YOU WILL NOT EXFOLIATE OR WAX YOUR FACE WITHIN 3 DAYS AND 3 DAYS AFTER YOUR APPOINTMENT
DO I HAVE AUTHORIZATION TO POST A BEFORE AND AFTER PROGRESS PICTURE? IF YOU ANSWER NO, I MAY STILL TAKE A PICTURE FOR REFERENCE OF YOUR SERVICE BUT IT WILL NOT BE POSTED.
I understand and 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 at OTGSS are voluntary and I release any skin care professional at On The Glow Skincare Studio from liability and assume full responsibility.
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