New Client Consultation Form

New Client Skincare Consultation

Please fill this form out if you are a new client or it has been more than 3 months since your last facial with me.
Date*

MonthDayYear
Name*

First NameLast Name
Date of Birth*
Phone Number*
E-mail*
example@example.com
How did you hear about Apotheke Skin*

Social MediaAn AdGoogleYelpA friend
If Referral, please list name
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 did you love about your last facial? What would you have changed?
How can I make this your favorite facial experience?
What Skin Care Products do you currently use?*

Cleanser / Face WashBar SoapFace Scrub / ExfoliantsTonerSerumsMoisturizerSunscreenEye Product(s)Lip Product(s)
If you are seeking corrective treatments please detail the SPECIFIC products (BRAND & PRODUCT TYPE/NAME) you are currently using so I can best answer any questions on ingredients and help you meet your skin care goals. Otherwise, skip this portion.
Cleanser / Face Wash
Bar Soap
Face Scrub / Exfoliants
Toner
Serums
Moisturizer(s)
Sunscreen
Eye Product(s)
Lip Product(s)
Have you received any Botox, Juvederm, or other dermal fillers in the last two months? Having these procedures done too close to your facial massage may move botox from injection site or cause other reactions.*

YesNo
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 14 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 ever experience an adverse reaction to a skincare treatment or product?*

YesNo
Knowing that consistent treatments and home care is a big part of achieving healthy skin, would you like to chat about how to maintain the results of your facial?

YesNo, I'm just here to relax.
If Yes, please explain.
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 SoresLupusDepression/AnxietyHepatitisHeadaches / MigrainesOtherNone
If you checked yes to any of these please provide further information.
Do you take any of the following dietary / health supplements?

MultivitaminVitamin CVitamin D/D3ZincOmega 3 / Fish OilB Complex / B12GarlicCalciumFolic AcidMelatoninCoenzyme Q10BiotinOther
Do you?*

Wear contact lensesHave a pacemakerHave metal implantsHave body piercingsNo, not Applicable
If other, please list
Any known allergies?*

AspirinTree NutsLatexDairyFruitsVegetablesShellfishIodineFragrances / Essential OilsOtherNone
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
Have you ever experienced claustrophobia? *

YesNo
Have you or do experience..*

Migraine headachesJaw pain, grinding, tension in jawSinusitisNone
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 I am breastfeedingN/A
Any menopause issues? *

YesNoN/A
If yes, please specify
Are you undergoing any hormone replacement therapy?

YesNo
If yes, please specify
MALE CLIENTS
What is your current shaving system?

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

YesNoN/A
Before/After photos are a great way to show my work to potential clients. Please select if it is ok to post/show your before/after to:

InstagramGoogle BusinessMy business websiteNo, please keep pictures private
Is there anything else you would like to share? Understanding your goals and lifestyle enables me to provide superior client experience.
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
Signature*

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New Client Skincare Consultation

Your Skin

Your Health