Facial consult
  • Date
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  • Date of Birth
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  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Married?
  • If yes, anniversary date
     / /
  • Does your job require that you work outdoors?

  • Your Skin Care

  • Have you ever had a facial treatment before?
  • Have you ever had any of the following body spa treatments?
  • Which of the following best describes your skin type?
  • Have you ever had chemical peels, laser or microdermabrasion?
  • Have you used an acne medication?
  • Have you recently used any self-tanning lotions, creams, or treatments?
  • Have you used any of the following air removal methods in the past 6 weeks?
  • What areas of concern do you have regarding your skin: (Please check all that apply)
  • Do you have allergies to the following?

  • Client Consultation- - continued

  • Do you use spf on your face?
  • 16 Have you had any recent tanning bed or sun exposure that changed the color of your skin?
  • Have you experienced Botox, Restylane or Collagen injections?
  • Female Clients Only: Are you taking oral contraceptives?
  • Are you undergoing any hormone replacement therapy
  • For future appointments/contact: How would you prefer we contact you:

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    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 received at Shanti Wellness are voluntary and I release this Shanti Wellness and my skin care professional from liability and assume full responsibility thereof.

  • Date
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  • Should be Empty: