Divinity Client Consultation Form
Language
  • English (US)
  • Español
  • I prefer ________ for appointment updates/offers and any other information regarding my service.*
  • Have you ever had a facial treatment before?*
  • Have you ever had a body treatment before?
  • What’s your Skin Type?*
  • Describe your Skin Type on the Fitzpatrick Scale*
  • Have you ever had an allergic reaction to any of the following? Check all that apply

  • Do you currently have any cold sores or open wounds?
  • Do you have any special skin problems or concerns pertaining to your face or body?*
  • Do you experience routine breakouts or acne?
  • Have you been diagnosed with eczema, psoriasis, or rosacea?
  • Have you experienced Botox, Restylane, or collagen injections in the past 2 weeks?*
  • Do you use Accutane, Retin-A, Renova, Adapalene Hydroxyl Acid or any other Retinol/vitamin A derivative products?*
  • Have you ever had chemicals peels, laser treatments, or microdermabrasion?*
  • In the last month?
  • What skincare products are you currently using? (Check all that apply)

  • 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.

  • What areas of concern do you have regarding your skin? (Check all that apply)*

  • Eyes (Check all that apply)*

  • Lips (Check all that apply)*

  • (optional) ADD ON $
  • WAXING CLIENTS ONLY - Have you used any hair removal methods in the past two weeks?

  • WAXING CLIENTS ONLY (Check all that apply to previous question)

  • How many glasses of water do you drink per day?*
  • How many caffeinated beverages coffee, tea, soda, etc do you consume per day?*
  • Which foods do you consume on a regular basis? (Check all that apply)*

  • How often do you wear SPF on your face?*
  • Do you? (Check all that apply)*
  • FEMALE CLIENTS: Are you taking birth control?
  • FEMALE CLIENTS: Are you pregnant, nursing or trying to become pregnant?*
  • MALE CLIENTS: Do you expereince irritation from shaving?
  • MALE CLIENTS: Do you experience ingrown hairs as a result of hair removal?
  • Have you been sick recently?*
  • Have you recently been diagnosed with COVID?*

  • 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!

  • I consent to photos/videos of my service to be featured on Instagram/Facebook. (Social media is my main source of marketing and promotes my small business)*
  • What's your skincare product budget?*

  • 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.

  • Today’s Date*
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