Divinity Client Consultation Form

NAME*
DATE OF BIRTH*

MonthDayYear
ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PHONE*
EMAIL*
example@example.com
Emergency Contact*
name, relation, phone number
textscallsemails
How did you hear about Divinity Esthetics?
YesNo
YesNo
If yes, what treatment? What was your favorite part?
What would you like to achieve from this treatment?*
Normal (neither oily nor dry, no visible blemishes, smooth texture)Dry (flaky, dry or red patches. tight skin)Oily (shiny appearance, enlarged pores, prone to acne & blackheads)Combination (both oily & dry areas, oily t-zone, hormonal breakouts. may be prone to blackheads & large pores)Sensitive (often irritated, may react with redness (rosacea, eczema, psoriasis)Acne (cystic or nodules)
Type l Fair- Always burns, never tansType ll Light-Burns easily, tans lightlyType lll Fair to Olive- Burns moderately, tans moderatelyType lV Light Brown- Burns slightly, tans easilyType V Dark Brown- Rarely burns, tans easilyType Vl Dark Brown to Black- Nevers burns, tans easily
AHA’s (Alpha Hydroxy Acids)FoodLatexMedicationsCosmeticsSkin Care Products/IngredientsSunscreenShellfishFragranceAnimalsIodineNone of the aboveOther
Please list allergies and describe what type of reaction(s) you had*
“None” if not applicable
YesNo
YesNo
If yes, please specify
YesNo
Yes, eczemaYes, psoriasisYes, rosaceaNo
YesNo
If yes, please specify
YesNo
If yes, please specify what and when last used
YesNo
YesNo
CleanserTonerMasqueDay MoisturizerNight MoisturizerSerumSPF/SunscreenVitamin A (retinol)Eye ProductExfoliatant (physical or chemical)Makeup ProductsBody ScrubBody LotionOther
PLEASE READ!!

Please list current skin care product name & brand in the provided boxes below or have a list prepared to bring into your facial appointment.

If you choose to bring a list of your current skin care products, please include the name and brand of each product. This will help me to recommend the best products custom to you and I may have you discontinue products not best suited for your skin.

list should include any face products used within the last 2 weeks.
Cleanser
(List brand if known)
Toner
(List brand if known)
Day Moisturizer
(List brand if known)
Night Moisturizer
(List brand if known)
Exfoliator
(List brand if known)
Scrub
(List brand if known)
Masque
(List brand if known)
Other
(List brand if known)
Eye Product
(List brand if known)
SPF/Sunscreen
(List brand if known)
Makeup Products
(List brands if known)
Soap
(List brand if known)
Shower Gel
(List brand if known)
Body Lotion
(List brand if known)
Other
(List brand if known)
BreakoutsSun DamageRosaceaFlaky SkinSun/liver/brown spotsUneven Skin ToneExcessive oil/shineDull/dry skinRednessBlackheads/whiteheadsWrinkles/fine linesBroken CapillariesDehydratedNone of the aboveOther
Dark CirclesWrinklesPuffinessDehydratedNone of the aboveOther
Cracked/chapped lipsDehydratedNone of the aboveOther
Lip Treatment $10Eye Treatment $10
YesNoOther
ShavingLaserWaxingThreadingSugaringTweezingElectrolysisNone of the aboveOther
01-23-56+
01-23-56+
FruitsVeggiesDairy/EggsCheesePoultrySeafoodGrains/BreadProcessed SugarProcessed MeatsOther
EverydayOccasionallyOnly when I’m outsideI don’t
Wear contact lensesExercise regularlyHave a pacemakerHave metal implantsSmoke tobacco products regularlyConsume alcohol regularlyConsume caffeine regularlyFrequently lay in tanning bedHave any metal plates/disksNone of the above
How is your stress level today on a scale from 1 to 5? 1 = low stress, 5 = high stress
YesNo
If yes, please specify:
YesNo
How far along/Expected due date:
FEMALE CLIENTS: Are you undergoing any hormone replacement therapy treatments? (Leave blank if NO)
YesNo
YesNo
YesNo
If yes, please explain the illness, and how long you have been symptom free.
YesNo
If yes, have you been treated and symptom free for more than 72 hours?
What size spa wrap will you need for your service? *
I diffuse essential oils and/or use a wax burner during services.

Steam towels may be infused with essential oil aromas.

Please notify me below if you have any aroma sensitivities or other questions.

Thank you!
Please type any more info you feel may be important below
YesNo
under $150$150-$200$200-$300$300+not surenot interested
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 here are voluntary and I release Divinity Esthetics and/or the technician/esthetician/skin care professional from liability and assume full responsibility thereof.
Client Name (Printed):*
Today’s Date*

MonthDayYear
Date
Signature*
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