Client Consultation Form
The purpose of this form is to capture information about the client that is relevant to the services provided by Milk & Honey Beauty Lounge, LLC. All clients are required to complete the consultation forms, and they must be reviewed by the appropriate client annually.
Client's Name
*
First Name
Last Name
What is your gender classification?
*
Please Select
Male
Female
Non-Binary
Client's Date of Birth
*
/
Month
/
Day
Year
Date
Client's Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Client's Email
*
example@example.com
How did you hear about us?
*
Which of our services are you interested in?
*
Facials/Treatments
New Skincare Products
Waxing
Spa Parties
Other
Name of Emergency Contact
*
First Name
Last Name
Cell Phone Number of Emergency Contact
*
Please enter a valid phone number.
Format: (000) 000-0000.
What is your occupation?
*
Do you have any known allergies?
*
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Current Facial Skin Care Products
Which of the following best describes your skin type?
*
I. Pale Complexion; Always Burns Easily, Never Tans
II. Light Complexion; Always Burns Easily, Tans Slightly
III. Light/Matte Complexion; Burns Moderately, Tans Gradually.
IV. Matte Complexion; Seldom Burns, Always Tans Well
V. Brown Complexion; Rarely Burns, Deep Tan
VI. Dark Brown Complexion; Rarely Burns, Deeply Pigmented
Do you currently have a daily skin care routine?
Of course!
Yes, but I’m not disciplined with it.
No
I want a professional and customized routine that will help correct my skin concerns!
Please upload a photo of your current skin care routine if you are looking to receive facial treatments or facial services.
Browse Files
Drag and drop files here
Choose a file
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Have you been under the care of a physician, dermatologist, or other medical professional within the past year? Yes or No. If yes, please explain.
*
Have you had any recent surgery, including plastic surgery? Yes or no. If yes, please explain.
*
Have you received any Botox, Dermal Fillers, Restylane or Collagen Injections in the last six months?
*
Have you been diagnosed with Cancer? If so, are you in remission?
*
List all prescribed and over the counter medications that you are currently taking regularly:
*
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Have you had any of these health conditions in the past or present?(Please check all that apply and provide additionalinformation in the space provided)
*
Cancer
Hormone Imbalance
Systematic Disease
High Blood Pressure
Spinal Injury
Thyroid Condition
Hysterectomy
Diabetes
Heart Conditions
Varicose Veins
Arthritis
Asthma
Eczema
Epilepsy
Seizure Disorders
Fever Blisters
Headaches (Chronic)
Hepatitis
Herpes
Cold Sores/Fever Blisters
Immune DisordersHIV/AIDS
Lupus
Metal Bone Pins or Plates
Phlebitis, Blood Clots, Poor Circulation
Blood Clotting Abnormalities
Psycological Treatment
Insomnia
Keloid Scarring
Skin Disease or Skin Lesions
Any Active Infections
None
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Do you smoke?
*
Yes
No
Do you follow a restricted diet? If Yes, Please Explain.
*
Do you follow a regular exercise program?
*
Yes
No
What is your stress level?
*
Please Select
High
Medium
Low
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What is your pressure preference for body massages?
Deep Tissue
Medium
Light
Customized
Have you ever received a professional facial treatment? If so, when was it and what was the treatment received?
*
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Do you use Retin-A, Renova, Adapalene Hydroxly Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid or Retinol/Vitamin-A derivative products? Have you used any of these products in the last 3 months? If yes to either question, please explain.
*
Do you use acne medication? If so, what is it called?
*
Do you form thick or raised scars from cuts or burns?
*
Yes
No
Do you experience hyperpigmentation (darkened skin) or hypopigmentation (lightened skin) after physical trauma?
*
Hyperpigmentation
Hypopigmentation
No
Both
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How many hours a night do you sleep?
*
How many ounces of water do you drink a day?
*
Do you wear contact lenses?
*
Yes
No
How frequently are you exposed to the sun or use a tanning bed?
*
Please Select
Infrequently
Frequently
Regularly
Do you have any metal implants or wear a pace maker?
*
Yes
No
Have you ever experienced Claustrophobia?
*
Yes
No
Are you undergoing any hormone replacement therapy?
*
Yes
No
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What is your current hair removal method?
Do you experience irritation from shaving?
Yes
No
N/A
Do you experience ingrown hairs from shaving?
Yes
No
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Female Clients Only
Are you taking oral contraceptives? If yes, please explain how long you have been taking them.
Are you pregnant or trying to become pregnant?
Yes, currently pregnant
Yes, trying
No
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Please use this space to complete answers where the space was insufficient.
If you could change one thing about your skin, what would it be?
*
Please take a forward facing photo of your face. This photo will not be used for any advertisement.
*
Does Milk & Honey Beauty Lounge have permission to use photos of your before and after progress and or service photos for advertisment on social media?
*
Yes
Yes, only if my eyes are hidden
No
Client Signature
*
Today's Date
*
-
Month
-
Day
Year
Date
Submit
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