New Client Consultation Form

New Client Consultation Form
Date*

MonthDayYear
Name*

First NameLast Name
Date of Birth*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
How did you hear about me?*

Website / Online SearchYelpFacebookReferralOther
If Other, please let me know
Your Skin
What are your skin care goals? *
What are your skin care challenges?*

Wrinkles / Fine LinesHyperpigmentation / Sun DamageAcne / Acne ScarringRedness / RosaceaAgingMelasmaSensitivityOther
Please feel free to go into more detail
Have you ever had a facial or skin treatment before?*

YesNo
If Yes, when?
What Skin Care Products do you currently use?*

Cleanser / Face WashBar SoapFace Scrub / ExfoliantsTonerSerumsMoisturizerSunscreenEye Product(s)Lip Product(s)
Cleanser / Face Wash
Bar Soap
Face Scrub / Exfoliants
Toner
Serums
Moisturizer(s)
Sunscreen
Eye Product(s)
Lip Product(s)
Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?*

Yes, currently usingYes, but not within the last 30 daysYes, but not within the last 6 monthsNoNot sure
Please specify which product or type, if you answered 'Yes, currently using' to above.
Have you received any of these hair removal services in the last 30 days?*

WaxingSugaringThreadingElectrolysis / LaserDepliatory CreamShavingNone
If checked, please note last time.
Have you ever received chemical peels, laser services, or microdermabrasion treatments? *

Yes, within the last monthYes, within the last 2-3 monthsNo
Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks?*

YesNo
Your Health
Have you experienced any of these health conditions in the past or present?*

Hormone ImbalanceCancer / Systemic DiseaseHigh Blood PressureDiabetesHeart problemArthritisAuto-Immune DisordersAsthmaEpilepsy / Seizure DisorderFever BlistersHerpesFrequent Cold SoresHIV/AIDSLupusDepression/AnxietyHepatitisHeadaches / MigrainesOtherNone
If you checked yes to any of these please provide further information. If not mark N/A*
Do you take any of the following dietary / health supplements?

MultivitaminVitamin CVitamin D/D3ZincOmega 3 / Fish OilB Complex / B12GarlicCalciumFolic AcidMelatoninCoenzyme Q10BiotinOther
If other, please list
Any known allergies?*

AspirinTree NutsLatexDairyFruitsVegetablesShellfishIodineFragrances / Essential OilsOtherNone
When you go out in the sun do you (Check which one)*

Always BurnUsually BurnSometimes BurnRarely BurnNever Burn
If Other, please specify
Have you used or been prescribed any medications (topical or oral) for acne / acne control?*

YesNo
If yes, please specify what and date last used
Are you a smoker? *

YesNoSocial
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)*

YesNo
Please rate your stress level*

LowMediumHigh
FEMALE CLIENTS
Are you taking birth control? *

YesNoN/A
If yes, what kind
Are you pregnant or trying to become pregnant?*

YesNoRecently had a baby and am breastfeedingN/A
If yes, please specify
Are you undergoing any hormone replacement therapy?

YesNo
MALE CLIENTS
What is your current shaving system? *

Razor / Wet shaveElectricN/A
Do you experience irritation from shaving? *

YesNoN/A
Reservation & Cancellation Policy for all current and future appointments: In the event of cancellations received less than 24 hours prior to appointment, a cancellation fee equal to the reserved service booking will incur.*

I understand the reservation and cancellation policies and consent to being charged if I fail to give 24 hour notice.
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 I receive here are voluntary and I release this skin care professional from liability and assume full responsibility thereof.

Yes
The treatment has been explained to me, and I have had the opportunity to ask questions. The effect and nature of the treatment to be given, as well as possible alternative methods of treatment, have been fully explained to me. I am advised that though good results are expected, they CANNOT and are not GUARANTEED to be effective. I agree to actively participate in the instructions and home care procedures and to read all the documentation given regarding the products and treatment before and after care instructions. I hereby acknowledge that all the information in this document is correct and I have left nothing out. I acknowledge that there is no guarantee that dark discolouration of skin will be reduced or fade. Pigmentation may improve or darken with successive treatments. I acknowledge that my skin may experience temporary irritation, tightness and redness. I acknowledge that if I fail to use minimal sunscreen (SPF 30), I am more susceptible to sunburn, skin damage and hyperpigmentation. I understand that I may be required to have photographs taken before and after treatments for my medical recordsI hereby acknowledge and agree to hold Heavenly Horizons harmless against any adverse reaction which could be sustained during or as a result of the products prescribed.

Yes
TRANSITIONAL PERIOD transitional period is a normal, temporary skin condition that may occur due to the introduction of specific active ingredients that have a positive effect on the function and structure of the skin. When starting with a new range of active products you may experience a transitional or crisis period. TYPICAL SYSTEMS THAT MAY BE EXPERIENCED: - Excessive oiliness- Excessive dryness or slight flakiness- Breakouts and/or underlying congestion - Increased sensitivity - Hyperpigmentation and capillaries may appear more visible due to the treatment process.

Yes
Signature*

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New Client Consultation Form

Your Skin

Your Health