ILLUME Appointment Policy and Intake Form
Confirmations are sent out 48hrs before your reserved time, please kindly inform us then if changes are required so your time may be given to another client and you will not be charged. Any changes to your appointment less than 48hrs before will result in a 50% cancellation fee.
Agree
Cancellations made less the 24hrs before appointment or failure to arrive for appointment time will be charged 100% of service.
Agree
Continuing to work together, you will share your skin and health status and any changes to each in full transparency at all appointments. You realize withholding information may result in contraindications and accept full responsibility if so.
*
Agree
Name
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Date of Birth
-
Month
-
Day
Year
Date
Please share with me your current skincare routine, as simple or complex as it may be, including product. This will help me understand your skin before we begin together and formulate a plan to achieve your best skin health.
Does your current routine bring you joy?
What words would you use to describe your skin?
What do you love about your skin?
Where would you like to see change (if any) in your skin?
Please tell me a bit of your skin history, including sensitivities, allergies, medications, injections, chemical peels, laser treatments, permanent cosmetics, tattoo, recent injections (within the past 6 months) etc.
Have you had recent injections?
Diet/digestion/gut microbiome health:
I feel good/balanced in this area
Imbalanced
This has been an issue in the past
Other
Stress level:
Low
Medium
Struggling to manage current stress level
Other
How do you manage stress? Include modalities: breath work, meditation, massage, acupuncture, walks in nature.
How much time do you dedicate to your skincare rituals?
How did you hear about me? Please list any referrals.
Please let me know if there is anything else you’d like to share.
As we continue to work together, I understand I must inform Illume Skin Therapy/ Holly Henton of any changes to my skin and health status for each future appointment.
Agree.
I look forward to working together.
Holly Henton
Illume Skin Therapy
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