Consultation
Skin Consultation Form
Contact / personal information
Please fill out this form to the best of your ability. This helps us understand where your skin is currently and how I can begin to address your concerns.
Name
*
First Name
Last Name
Suffix
Address
*
Street Address
Street Address Line 2
City
County
Zip code
Phone Number
*
-
Area Code
Phone Number
E-mail
*
example@example.com
How did you hear about Justified Skin Esthetics?
*
Were you referred by someone? If yes, please provide their name here.
Health questionnaire
Have you ever been under a dermatologist or physician's care? If yes, when?
*
Have you undergone any surgery in the last two years?
*
Yes
No
Please list any surgeries you had in the last two years (if applicable).
Do you have any metal implants, pacemakers, or piercings? If yes, please list.
*
Please list any medications / supplements / vitamins you are currently taking
*
Please list any allergies you have:
*
Do you wear contact lenses?
*
Yes
No
Do you smoke?
*
Yes
No
Occasionally
On a scale of 1-5, how would you rate your stress? (1 = low, 5 = high)
*
Please select any medication you are currently using or have used:
*
Retinol
Glycolic Acid
Salicylic Acid
Topical Steroids
Benzoyl Peroxide (BPO)
Topical Antibiotics
Roaccutane
N / a
Other
Reproductive health
Please skip if this section does not apply to you.
Are you currently due for or on your menstrual cycle?
Yes
No
N/A
Are you currently or trying to become pregnant?
Yes
No
N/A
Are you taking any form of birth control?
Yes
No
N/A
Are you currently lactating or breastfeeding?
Yes
No
N/A
Addressing Your skin
Let's learn about your skin:
What are your skin care goals??
*
Do you currently follow a skincare routine?
*
Yes
No
What skin care products are you currently using?
After washing your face, how soon do you experience an oily shine?
Almost immediately
Mid-day
End of day
N/A
What is skin goal the goal you’d like to accomplish in this appointment (Relaxation, address dark spots, etc…)
*
At what age did you notice your skin change?
*
Do you use SPF/ sunscreen?
*
Yes
No
Please select any skin concerns you believe you are experiencing:
*
Acne
Sensitivity
Oiliness
Dry
Signs of aging / Wrinkles / Fine lines
Blackheads / Whiteheads
Dehydrated
Uneven Skin tone / dark spots
Sun Damage
Rosacea
Flaky Skin
Broken Capillaries / Broken Veins
Peeling skin
Other
Do you sunbathe or participate in outdoor activities? If yes, please list the activity(ies).
*
Take a photo of your skin concerns in advance (Not a requirement)
If you’re under a dermatologist’s care, what has your dermatologist prescribed you?
What does your skin feel like in your T-Zone (forehead to nose) area?
*
Do YOu exercise?
Yes
no
Occasionally
Inconsistently
What is your daily water intake?
*
what is your daily caffeine intake?
*
How much alcohol do you consume on a weekly basis?
In a few sentences, describe your diet on a daily basis (please provide details):
*
Have you ever had any kind OF chemical exfoliant such as Chemical peels? If so, were they done in a medical setting?
Preferences
What type of massage do you prefer?
*
Light
Medium
Firm
What is your pain threshold?
*
Low
Average
High
Have you ever experienced claustrophobia?
*
Yes
No
What music genre would you like during your appointment?
R & B, spa music, instrumental, etc...
Silent appointment?
Yes please!
No thank you
Sign form
See you at your appointment!
Date
*
/
Month
/
Day
Year
Enter today’s date
Signature
*
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