Facial Consultation Form

Name

First NameLast Name

Phone Number

Area CodePhone Number

Email

example@example.com

How did you hear about me?

What would you like to achieve from your treatment today?

YOUR SKIN: the questions below will pertain to your skin and your concerns, please answer them honestly and to the best of your ability ☻

Have you ever had a facial treatment before?

Do you have any special skin problems or concerns pertaining to your face? If yes, please specify

Have you ever had chemical peels, laser or microdermabrasion? If yes, please specify when

Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products? If yes, please describe

Have you used any of the previously listed products in the last 3 months?

Have you used an acne medication?

What acne medication have you used? ("n/a" if not applicable)

When was the last time you used acne medication? ("n/a" if not applicable)

Current Skincare Routine

Rows	Please Check
Cleanser
Toner
AM Moisturizer
PM Moisturizer
SPF
Eye Cream
Serum
Mask

Have you recently used any self-tanning lotions, creams or treatments?

Have you used any hair removal methods in the past six weeks? If yes, please list

Area of Concern - SKIN:

Rows	Please Check All That Apply
Breakouts/ Acne
Blackheads/ Whiteheads
Excessive Oil/ Shine
Rosacea
Broken Capillaries
Redness/ Ruddiness
Sun Spot/ Liver Spot/ Brown Spot
Uneven Skintone
Sun Damage
Wrinkles/ Fine Lines
Dull/ Dry Skin
Flaky Skin
Dehydrated Skin
Other

Areas of Concern - EYES:

Rows	Please Check All That Apply
Dehydrated
Wrinkles
Puffiness
Dark Circles
Other

Areas of Concern - LIPS:

Rows	Please Check All That Apply
Dehydrated
Dry/ Cracked Lips
Wrinkles/ Fine Lines

Have you ever had an allergic reaction to any of the following?

Rows	Please Check All That Apply
Cosmetics
Medicine
Food
Animals
Sunscreens
Pollen
Alpha Hydroxy Acids
Fragrance
Shellfish
Latex
Drugs
Other

If Other, please list:

What SPF do you use on your face?

How often? When?

Have you had any recent tanning bed or sun exposure that changed the color of your skin?

Do you spend extended periods of time exposed to the sun on a regular basis?

Have you experienced Botox, Restylane or Collagen injections?

Are you undergoing any hormone replacement therapy?

Are you taking oral contraceptives, pregnant/trying to become pregnant, or lactating? ("n/a" if not applicable)

Any recent changes to or from your contraceptive treatment? ("n/a" if not applicable)

There will be a short décolleté massage included. Are there any parts of your body (shoulders and up) that you would like me to avoid? (ex. hair, ears, neck)

I give Beauty Del Mar permission to take and use my before and after photos for marketing purposes.

Would you like a silent appointment?

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 institution and/or skin care professional from liability and assume full responsibility thereof.

There will be a 10 minute grace period for all appointments, anything past 10 minutes is subject to cancellation. NO CALL/NO SHOWS will be charged full amount of service. I kindly ask that you provide a 24 hour notice if you need to cancel or reschedule your appointment. Anything within 24 hours will result in loss of deposit and charge of 50% of the service/s you had booked. You may transfer your deposit once as long as the new appointment is made within a 30 day period. All services are non-refundable.

Signature

Date: