New Client Consultation Form

Consultation Consent Form

Advanced Skin Care Treatments
Date*

MonthDayYear
Date
Full Name*

First NameMiddle NameLast Name
Date of Birth*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
Website / Online SearchYelpFacebookReferralOtherInstagramFriendGoogleGrouponTik Tok
If Referral, please list name
If Other, please let me know
Your Skin
What are your skin care goals? *
Wrinkles / Fine LinesHyperpigmentation / Sun DamageAcne Scarring / TextureAging dull looking skinMelasmaSagging / Loose skinStretch MarksOtherOther
YesNo
If Yes, when and what was it ?
Cleanser / Face WashBar SoapFace Scrub / ExfoliantsTonerSerumsMoisturizerSunscreenEye Product(s)Lip Product(s)
Yes, currently usingYes, but not within the last 30 daysYes, but not within the last 6 monthsNoNot sure
Please specify which product or type, if you answered 'Yes, currently using' to above.
WaxingSugaringThreadingElectrolysis / LaserDepliatory CreamShavingNone
If checked, please note last time.
Yes, within the last monthYes, within the last 2-3 monthsNo
YesNo
Your Health
Hormone ImbalanceCancer / Systemic DiseaseHigh Blood PressureDiabetesHeart problemArthritisAuto-Immune DisordersAsthmaEpilepsy / Seizure DisorderFever BlistersHerpesFrequent Cold SoresHIV/AIDSLupusDepression/AnxietyHepatitisHeadaches / MigrainesOtherNone
If you checked yes to any of these please provide further information. If not mark N/A
Wear contact lensesHave a pacemakerHave metal implantsHave body piercingsNo, not Applicable
MultivitaminVitamin CVitamin D/D3ZincOmega 3 / Fish OilB Complex / B12GarlicCalciumFolic AcidMelatoninCoenzyme Q10BiotinOther
If other, please list
Colloidal SilverTree NutsLatexDairyFruitsVegetablesShellfishIodineFragrances / Essential OilsSalicylic AcidNone
If Other, please specify
YesNo
If yes, please specify which one and latest date taken oral/topical treatment medication
YesNoSocial
YesNo
Do you have a pacemaker?*
LowMediumHigh
FEMALE CLIENTS
YesNoRecently had a baby and am breastfeedingN/A
If yes, please specify
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 at Honeydew Youth are voluntary and I release this skin care professional, Crystal from liability and assume full responsibility thereof.*

Yes I understand
Upload Driver License or any form of ID with name and picture *

Browse Files

Cancelof
Signature*

Clear
Should be Empty:

Consultation Consent Form

Your Skin

Your Health