New Client Consultation Form
Date
*
-
Month
-
Day
Year
Date Picker Icon
Name
*
First Name
Last Name
Date of Birth
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
E-mail
*
How did you hear about us?
Instagram
Facebook
Referral
Other
If Referral, please list name
Occupation
*
Your Skin
What are your skin care goals?
*
What are your skin care challenges?
*
Wrinkles / Fine Lines
Hyperpigmentation / Sun Damage
Acne / Acne Scarring
Redness / Rosacea
Aging
Melasma
Sensitivity
Dryness
Oiliness
Other
Please go into more detail
Have you ever had a facial or any skin treatment before?
*
Yes
No
If Yes, when?
What Skin Care Products do you currently use?
*
Cleanser / Face Wash
Bar Soap
Face Scrub / Exfoliants
Toner
Serums
Moisturizer
Sunscreen
Eye 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.
Cleanser / Face Wash
Bar Soap
Face Scrub / Exfoliants
Toner
Serums
Moisturizer(s)
Sunscreen
Eye Product(s)
Lip Product(s)
What is your budget for an at home regimen? (this is not monthly, it is more based off every 6 months)
*
$100-$200
$200-$400
$400-$600
$600-$1,000
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 using
Yes, but not within the last 30 days
Yes, but not within the last 6 months
No
Not 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 30 days?
*
Waxing
Sugaring
Threading
Electrolysis / Laser
Depliatory Cream
Shaving
None
If checked, please note last time.
Have you ever received chemical peels, laser services, or microdermabrasion treatments?
*
Yes, within the last month
Yes, within the last 2-3 months
No
Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks?
*
Yes
No
Your Health
Have you experienced any of these health conditions in the past or present?
*
Hormone Imbalance
Cancer / Systemic Disease
High Blood Pressure
Diabetes
Heart problem
Arthritis
Auto-Immune Disorders
Asthma
Epilepsy / Seizure Disorder
Fever Blisters
Herpes
Frequent Cold Sores
HIV/AIDS
Lupus
Depression/Anxiety
Hepatitis
Headaches / Migraines
Endometriosis
PCOS
Other
None
If you checked yes to any of these please provide further information. If not mark N/A
*
Do you?
*
Wear contact lenses
Have a pacemaker
Have metal implants
Have body piercings
Wear a mask for work
None
Do you take any of the following dietary / health supplements?
Multivitamin
Vitamin C
Vitamin D/D3
Zinc
Omega 3 / Fish Oil
B Complex / B12
Garlic
Calcium
Folic Acid
Melatonin
Coenzyme Q10
Biotin
Other
If other, please list
Any known allergies?
*
Aspirin
Tree Nuts
Latex
Dairy
Fruits
Vegetables
Shellfish
Iodine
Fragrances / Essential Oils
Other
None
If Other, please specify
Have you used or been prescribed any medications (topical or oral) for acne / acne control?
*
Yes
No
If yes, please specify what and date last used
Are you a smoker?
*
Yes
No
Social
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)
*
Yes
No
Have you ever experienced claustrophobia?
*
Yes
No
Please rate your stress level
*
Low
Medium
High
FEMALE CLIENTS
Are you taking birth control?
*
Yes
No
N/A
If yes, what kind
Are you pregnant or trying to become pregnant?
*
Yes
No
Recently had a baby and am breastfeeding
N/A
Any menopause issues?
*
Yes
No
N/A
If yes, please specify
Are you undergoing any hormone replacement therapy?
Yes
No
If yes, please specify
Reservation & Cancellation Policy for all current and future appointments: A non refundable $100 booking fee will be charged at the time of reservation and goes towards appointment; a valid credit card is required for all appointments. Please do not forget to confirm your appointment when you receive your reminder from Square. In the event of cancellations received less than 72 hours prior to appointment, a cancellation fee equal to the $100 booking fee will be charged. No Shows will be charged the FULL amount equal to their scheduled service. Booking fees are NONREFUNDABLE if you cancel at any point. Ex: if you're scheduling an appointment for 12/25, the $100 booking fee would go towards the appointment on 12/25. If a cancellation occurs that $100 booking fee is nonrefundable, FOR EVERY DEBIT / CREDIT CARD TRANSACTION THERE WILL BE A 3% FEE, FOR EVERY AFTERPAY TRANSACTION THERE WILL BE A 6% FEE.
*
I understand the reservation and cancellation policies at Radiant Skin Aesthetics and consent to my credit card on file being charged if I fail to give 48 hour notice for appointments.
I understand that Radiant Skin Aesthetics reserves the right to terminate me as a client from their practice if I reschedule or cancel 3 or more consecutive appointments in a row. This includes illnesses such as COVID-19.
*
YES
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
I understand that no specific guarantees of the results can or have been made and that there is the possibility I may require additional treatments/procedures to obtain the expected results at an additional cost. I understand all pre/post treatment instructions and I understand the importance of following the instructions given to me. I hereby consent to any treatments offered at Radiant Skin Aesthetics (Chemical Peels, Dermaplaning, Hydrofacials, Microneedling, Waxing, Spray Tanning & all other treatments offered at Radiant Skin Aesthetics). Although it is impossible to list every potential risk and complication, I understand that there are risks, benefits and complications associated with any/all treatments. I understand that Radiant Skin will not be held liable for any complications, reactions, or side effects that may occur and I am agreeing to undergo all treatments provided by Radiant Skin at my own risk.
*
YES
Signature
*
I consent to "before & after" photographs for the purpose of documentation, potential advertising, and promotional purposes.
Submit
Should be Empty: