Flashed Out Facials & Lashes
NEW CLIENT Facial Consultation, Consent, & Skin Questionnaire Please take your time, fill out each question with detail and honesty. This will help us provide the best treatments and recommendations for you and your skin!
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birthdate
-
Month
-
Day
Year
Date
How did you find us?
Google
Facebook
Instagram
Janesville Athletic Club Ad
Friend
Attending a Facial Party
Other
Have you ever had a facial before?
Yes
No
If a friend referred you please put their name below to be eligible for our referral discount! ( Refer a friend: you and that friend will receive $15 off any service! ) *NOT ELIGIBLE FOR FACIAL PARTIES*
Please indicate which services you are interested in:
Skin Care Consultation / Advice
Home Care Products
Age Treatment / Management
Rosacea Management
Relaxation & Rejuvination
Acne Treatment / Management
Other
Are you currently, or have you previously experienced any of the following
Heart condition
Pacemaker
Headaches
Anemia
Low blood pressure
Cancer
Thyroid condition
Kidney problems
High blood pressure
Arthritis
Hemophilia
Asthema
Diabetes
Hypo/Hyper glycemia
Hepatitis
Herpes Simplex
AIDS/HIV Positive
Autoimmune
Contact Lenses
Cold Sores
None
If you are currently experiencing or being treated for any health-related condition, please describe:
Have you ever had a surgical or non surgical procedure? If yes, where on your body was the surgery performed? When did you have this procedure done?
Have you had any botox or filler within the last 2 weeks?
Yes
No
Do you have any allergies? Also, list any skin treatment products you have used that caused an unexpected reaction or side-effect:
Are you taking any skin, hair, or nail supplements?
Yes
No
If yes, please list the supplement:
Please list all over-the-counter and prescription medications you are currently taking:
Please indicate if you have ever used any of the following medications for skin treatment:
Accutane
Cortisone
Staticin
Benzoyl Peroxide
Retin A
Sulfer
DesquamX
Zerac
Fosdex
Glycolic Acid
Salicylic Acid
Lactic Acid
Renova
Clindamycin
Tazoratene
Metrogel
NONE
What condition were you treating with this medication(s) listed above?
When was the last time you used these medications?
Are you pregnant?
Yes
No
N/A
Are you planning on pregnancy in the near future?
Yes
No
N/A
Are you on any type of hormone therapy? If yes, please describe:
Do you have regular periods?
Yes
No
N/A
Do you have any hormone imbalance?
Yes
No
Are you going through menopause?
Yes
No
N/A
Have you undergone surgical menopause (hysterectomy)
Yes
No
N/A
How active is your lifestyle?
Not Active
Sometimes Active (1-2 days a week)
Frequently Active (3-4 days a week)
Active Daily (5-6+ days a week)
How many average hours of sleep do you get each night?
How are your stress levels currently?
Low
Medium
High
Unknown
Do you work around excessive heat or cold temperatures?
Yes
No
How many hours a week do you use a tanning bed?
Please indicate any of the following that apply to your eating habits
Fast food
Baked bread
Spicy foods
Dairy products
Seafood
Peanuts
Peanut butter
Salt on your food
Processed foods
Do you smoke tobacco products?
Yes
No
What is your average alcohol consumption per week?
Please describe your AM skincare routine and each product that you use. (Please be as detailed as possible!)
Please describe your PM skincare routine and each product that you use. (Please be as detailed as possible!)
Are you wearing a daily sunscreen? If so, please list the TYPE (mineral or chemical) Brand & SPF:
What are you using to dry your face?
Tell me what you love about the products you currently use.
Is there anything you wish your skincare products could do for your skin?
How would you describe your skin type?
Oily or acne prone
Dry
Normal
Sensitive
Combination
Unknown
Please tell me your overall skin goals! What would you like to achieve with your skin. I want this to be the best customized experience catered to you and your skin :)
What are your TOP 3 concerns you would like to address today? (ex. 1. Acne 2. Dark Spots 3. Tight irritated skin)
Are you confident in your skin currently?
Yes
No
I don't know
I haven't really thought about it
Are you interested in product recommendations and a customized skincare routine based on your skin analysis done the day of your facial?
Absolutely!
Maybe
I don't know
No, I love the routine I currently use on my skin
What is your ideal monthly budget for skincare products?
Have you ever treated or been treated for a skin condition? If yes, what condition?
How did you treat the condition:
Dermatologist
Aesthetician
Self treated with products
Were you happy with the result?
Yes
No
Are you currently treating or being treated for any skin condition? If so, what condition?
Any treatment we provide may consist of surface cleansing, superficial chemical peels, steam, exfoliation, application of antibacterial serums, corrective serums, and extractions. Treatments are designed to balance, hydrate, clear acne impactions, and prepare the skin for a home care regimen. Although rare, skin care treatments can have certain side effects such as erythema, bleeding,temporary scarring, dryness, discomfort, redness, rash, swelling, tenderness, etc. I hereby consent to and authorize Tayla and/or Jillian to perform any of the treatments listed above. I have voluntarily elected to undergo this treatment. Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications. I also recognize there are no guaranteed results and that independent results are dependent on age, skin condition, and lifestyle and that there is the possibility I may require further treatments of the treated areas to obtain the expected results at an additional cost. I understand the post treatment home care instructions. I understand how important it is to follow all instructions given to me for post treatment care. In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post treatment care, I will consult Tayla or Jillian 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 and all information detailed above. I understand the treatment 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 Tayla and/or Jillian responsible for any of my conditions that were present, but not disclosed at the time of the skin care procedure,which may be affected by the treatment performed. I consent to treatment today and all subsequent treatments. PHOTO RELEASE I understand that photographs may be taken before, during and after treatment. I give permission for photographs to be used by Tayla and/or Jillian for educational and/or promotional purposes. Complete patient confidentiality will be maintained at all times. POLICY All sales are final. Flashed Out Facials and Lashes does not refund any service for any reason. By signing you agree to pay the full amount of any service that is booked and received at the end of each appointment. CANCELLATION/RESCHEDULING GUIDELINES We realize emergencies happen and will be considered, however, it is our business policy to charge a 50% cancellation fee for any cancellations within 24 hours of the scheduled appointment. You will be charged for the full price of the service if you 'no call, no show'. After three online cancellations with no rebook you will no longer have access to online booking. We will require a $30 non-refundable deposit that will go towards the service you want to book. If you need to cancel before 24 hours you will not get the deposit back. You will be allowed to reschedule one time before needing to put down a new deposit.
Parent or Guardian Signature (If the client is under the age of 18 a parent/guardian MUST be present during the scheduled appointment!)
Submit
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