Facial Client Consultation Form
Dorset Bowen
What is your current Title?
Mrs
Miss
Mr
Ms
Dr
Other
Client's Name
*
First Name
Last Name
Gender
Male
Female
Date of Birth
*
-
Day
-
Month
Year
Date
Phone Number
*
-
Area Code
Phone Number
Email Address
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
Do you have any of the following conditions? If yes, please select them:
Cancer
Metal Implants
Pacemaker or Defibrillator
Diabetes
Claustrophobia
Heart Disease
Thyroid Disorder
Hysterectomy
Hormonal Imbalance
Epilepsy or Seizures
Blush Easily
HIV AIDS
Migraines/Headaches
Depression/Anxiety
Psoriasis
Rosacea
Eczema
Bruise Easily
Spinal Cord Injury
Immune Disorder
Lupus
Keloid Scarring
Skin Disease
Fibromyalgia
Menopause
Circulation Disorder
Varicose Veins
Other
Skin condition
Normal
Oily
Dry
Acne
Sensitive
Other
What are your main concerns with your skin?
Lines & wrinkles
Pigmentation
Scaring
Acne
Congestion (spots, blackheads)
Other
Do you have any allergies or are highly sensitive to any products?
*
Do you have any skin conditions that a facial may upset?
What is your daily skincare routine morning & evening?
Do you smoke?
Do you consume alcohol?
Yes
No
Are you pregnant?
Yes
No
Are you taking any contraceptive pills?
Yes
No
Are you breastfeeding?
Yes
No
Are you wearing any contact lenses?
Yes
No
Are you under the GP's care for your skin (acne, eczema)?
Benzoyl peroxide
Retinoids - Tretinoin
Retinoids - Adapalene
Azelaic acid
Have you undergone any surgeries in the last 6 months?
*
Yes
No
Please give details if you have had any surgery.
Is there anything else you feel I should be aware of
Date Signed
-
Day
-
Month
Year
Date
Client Signature
Print Form
Submit
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