Facial Client Questionnare
Name
*
First Name
Last Name
Appointment Date
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Date of birth
*
Email
*
example@example.com
Who were you referred by (name)?
*
Have you had a facial before?
*
Please Select
Yes
No
What are your specific skin care concerns?
*
Dry/Flaky
Age/Sun Spots
Fine Lines
Excess Oil
Redness/Sensitivity
Blackheads
Breakouts
None
Other
What skin care products are you using at home?
*
Cleanser
Toner
Exfoliant/Scrub
Serum
Moisturizer-Day
Moisturizer-Night
Eye Cream
Are you pregnant, lactating or plan on becoming pregnant soon?
*
Yes
No
Are you diabetic?
*
Yes
No
Do you have any kind of active cancer?
*
Yes
No
List all known allergies (food, products, ingredients, etc)
*
Have you ever had a reaction to skin care products or ingredients?
*
Yes
No
If yes, please explain
Are you using any prescribed exfoliants? (Retin-A, Diferen, etc)
*
Yes
No
How often?
Are you under the care of a doctor for an auto immune disorder?
*
Yes
No
Are you currently taking any medication that could interfere with a facial treatment?
*
Yes
No
If yes, please explain
How many ounces of water do you drink daily?
*
On average, how many hours of sleep do you get each night?
*
On a scale of 1-10, what is your current stress level? (10 being highest)
*
Do you take vitamins / supplements?
*
Yes
No
I understand that redness, sensitivity, peeling or other reactions may occur from facial treatments. If I experience any discomfort during the session, I will immediately inform the esthetician so that the products and/or technique may be adjusted to my level of comfort. I further understand that estheticians are not qualified to diagnose, prescribe or treat any disease or illness and that a facial should not be a replacement for medical treatment. The treatments I received here are voluntary and I release Dolce Medical Spa, Organic Salon and Salt Room and/or skin care professional from liability and assume full responsibility thereof.
*
By clicking here I acknowledge the above statement
By typing my name below, I acknowledge this document.
*
Submit
Should be Empty:
Now create your own Jotform - It's free!
Create your own Jotform