FACIAL CLIENT CONSULTATION FORM
Name
Date
/
Month
/
Day
Year
Date
Address:
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Age
Occupation
Referred By
Do you have any allergies to food, cosmetics, or drugs?
Yes
No
If yes, please list
Do you have any of the following
Sunburn
Moles
Eczema
Phlebitis
Psoriasis
High Blood Pressure
Asthma
Diabetes
Skin Cancer
HIV
Hepatitis
Heart Problems
Epilepsy
Lupus
Hemophilia
Other
On birth control / hormone replacement?
Yes
No
Are you taking any medications?
Yes
No
If yes, please list
Are you under the care of a skin care therapist, physician, or dermatologist?
Yes
No
Are you or have you been using or taking any of the following?
Acne Medication
Products Containing
Vitamin A Therapies
Hydroquinone
Alpha Hydroxyl
Have you had any of the following procedures?
Laser Resurfacing
Chemical Peel
Botox or Collagen Injections
Other
Date of Last Treatment
/
Month
/
Day
Year
Date
Have you had a facial before?
Yes
No
Date of Last Facial
/
Month
/
Day
Year
Date
Do you have any areas of concern?
How does you skin react to the sun?
Do you experience frequent blemishes? How frequently?
Have you ever experienced burning, itching, redness, or irritation?
What products do you currently use?
Soap
Cleanser
Toner
Exfoliate or Scrub
What products do you currently use?
Mask
Moisturizer
Sunscreen
What brand name?
Client Signature
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