The Skin Canopy Consultation Intake

CONSULTATION FORM

At The Loft - 1600 Hillyer Robinson Industrial Pkwy S. Suite B, Oxford, AL 36203
PERSONAL INFORMATION
Name
Date of Birth

MonthDayYear
Date
MFOther
Address
City
State
Zip
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Personal Health History
Blood Clot DisorderHeart DiseaseMenopauseBlush EasilyHepatitis A/B/CMetal ImplantsBruise EasilyHIV AIDSMigraines/HeadachesCancerHormonal ImbalanceCirculation DisorderHypertensionPacemaker or DefibrillatorClaustrophobiaHypotensionPsoriasis RosaceaDepression/AnxietyHysterectomySkin DiseaseDiabetesImmune DisorderSpinal Cord InjuryEczemaKeloid ScaringThyroid DisorderEpilepsy or SeizuresLupusVaricose VeinsFibromyalgiaOther
Please list any allergies below:
Do you currently have any acne?
NoneMildModerateSevere
Please list any current medications/supplements
YesNo
Have you undergone any surgeries?
Are you currently under any kind of diet?
Are you wearing any contact lenses?
Are you taking any contraceptive pills?
Are you trying or planning to be pregnant?
Do you have any hyperpigmentation (darkening of the skin) or hypopigmentation (lightening of the skin, marks after physical trauma, or scarring (from acne, etc)?
SKIN CARE AND SOCIAL HISTORY
Average hours of sleep per night?
Average daily water consumption (cups)?
Average daily caffiene consumption (cups)?
Average alcohol consumption?
Do you smoke? How much per day?

Please take a moment to consider the following:

Rows	Zero	Minimal	Moderate	High
Current Average Stress Level
Exerecise
Meditation/Prayer

Have you been exposed to the sun or used a tanning bed in the last 48 hours?
FrequentlyRegularlyInfrequently
DailyOccasionallyNever
Have you ever had a facial treatment before? When?
Have you ever had chemical peels, dermaplaning, hydrafacial, laser treatment, microdermabrasion, or any other services performed on your face, back, or neck by a doctor, esthitician or other service provider?
YesNo
Have you ever received Botox? If so, when?
Have you ever received fillers? If so, when?
Have you ever received chemical peels? If so, when?
Do you use Retin-A, Adapalene Hydroxl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid, or Retinol/Vitamin A derivative products? If yes, describe:
YesNo
SugaringShavingWaxingPluckingElectrolysisTweezingTherading
RashIrritationPeelingSun SensitivityBreakoutOther
Please describe your current morning skincare routine:
Please describe your current evening skincare routine:
Eye Make-Up RemoverDay Cream/MoisturizerMaskCleansing CreamNight CreamFacial ScrubFacial SoapEye CreamChemical ExfoliantsSkin Toner/AstringentNeck CreamBody Lotion/CreamBody SoapHand CreamBody ScrubSunscreen
Very DrySomewhat Dry/NormalNormalSomewhat Oily/NormalOilyCombination (Oily AND Dry)
What are your main skin concerns/issues?
What are your skincare/overall wellness goals?
TERMS & CONDITIONS
My signature below indicates I understand, have read and answered this questionnaire truthfully. I agree that this constitutes full disclosure and that it supercedes any previous verbal or written disclosures. I certify that the preceding medical, personal, and skin history statements are true and correct. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to my skin from treatments received. I am aware that it is my responsibility to inform the esthitician/skin care therapist of any current medical or health conditions and update this history as needed. The treatments I receive here are voluntary and I release The Skin Canopy LLC and/or Wittney Fratt Snyder from liability and assume full responsibility thereof. I accept arbitration as a means of resolution for practice liability.
Name
Signature

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Date

MonthDayYear
Date

CLIENT CONSENT FORM
Skincare ConsultationCosmetic ConsultationCosmetic TutorialFacialDermaplaneCuppingManual Lymphatic DrainageGua Sha Massage
I have voluntarily elected to undergo this treatment/procedure after the nature and purpose of this treatment have been explained to me, along with the risks and hazards involved, by Wittney Fratt Snyder.

Although it is impossible to list every potential risk and complication, I have been informed of the benefits, risks, and complications. I also recognize there are no guaranteed results and that independent results are dependent upon age, skin condition, and lifestyle, and that there is the possibility I may require further treatment of the treated areas to obtain the expected results at additional cost.

I understand how important it is to follow all instructions given to me for post-treatment care. In the event that I have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult The Skin Canopy immediately.

I have also, to the best of my knowledge, given an accurate account of my medical history, including all known allergies or prescription drugs, or products I am currently ingesting or using topically.

I have read and fully understand this agreement anf all information detailed above. I understand the procedure and accept the risks. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I do not hold Wittney Fratt Snyder or The Skin Canopy LLC responsible for any of my conditions that were present, but not disclosed, at the time of this skin care procedure, which may be affected by the treatment performed today.
Name

First NameLast Name
Client Signature

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CONSULTATION FORM

PERSONAL INFORMATION

Personal Health History

SKIN CARE AND SOCIAL HISTORY

TERMS & CONDITIONS

CLIENT CONSENT FORM