New Client Consultation Form

New Client Skincare Consultation Form

Please answer the following questions to the best of your ability. This form MUST be filled out & be placed on file before we begin your first appointment with Skin & Massage Spa By Bella.
Date*

MonthDayYear
Name*

First NameLast Name
Date of Birth*
Address*

Street Address

Street Address Line 2

CityState

Post CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
How did you hear about us?*

Website / Online SearchFacebookInstagramReferralOther
If you were referred, please let us know who from
If Other, please let us know
What is you occupation?*
Please select all the options that interest you or that you have questions about:

FacialDermaplaneChemical PeelMicroneedlingBrow LaminationMicrodermabrasionBrow or Facial Wax
Your Skin
What are your skin goals and objectives? *
What are your skin care challenges?*

Fine Lines/ WrinklesHyperpigmentation / Sun DamageAcne / Acne ScarringRedness / RosaceaAgingMelasmaSensitivityBlackheads/ WhiteheadsDry, flaky skinClogged PoresUneven Skin ToneMiliaOily SkinOther
Please feel free to go into more detail
Have you ever had a facial or skin treatment before?*

YesNo
If Yes, when?
How often do you wear makeup?*

Only for occasions1-2 times per week3+ days per week
What Skin Care Products do you currently use?*

Cleanser / Face WashBar SoapFace Scrub / ExfoliantsTonerSerumsMoisturizerSunscreenEye Product(s)Lip Product(s)MaskTreatment
Please detail the SPECIFIC products (BRAND & PRODUCT TYPE/NAME) you are currently using so we can best answer any questions on ingredients and help you meet your skin goals.
Cleanser / Face Wash
Soap
Face Scrub / Exfoliants
Toner
Serums
Moisturiser(s)
Sunscreen
Eye Product(s)
Lip Product(s)
Masks or Treatment
Do you/have you used Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?*

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
Have you ever received chemical peels, laser services, or microdermabrasion treatments? *

Yes, within the last monthYes, within the last 2-3 monthsNoNot sure
Have you received any of these services in the last 60 days?*

FillersBotoxThreadsAnti-Wrinkle InjectionsLaserSkin TreatmentsNone
If yes, please specify
Your Health
Have you experienced any of these health conditions in the past or present?*

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*
Do you?*

Wear contact lensesHave a pacemakerHave metal implantsHave body piercingsNo, not Applicable
Do you take any of the following dietary / health supplements?

MultivitaminVitamin CVitamin D/D3ZincOmega 3 / Fish OilB Complex / B12GarlicCalciumFolic AcidMelatoninCoenzyme Q10BiotinCollagen PowderOther
Please check any topical or oral medications you are currently using or have used in the last 6 weeks.*

AccutaneDifferinRetin-ARenovaTazoracAntibioticsBirth ControlOtherNone of the above
Any known allergies?*

AspirinTree NutsLatexDairyFruitsVegetablesShellfishIodineFragrances / Essential OilsNoneOther
Are you a smoker? *

YesNoSocial
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)*

YesNo
Have you ever experienced claustrophobia? *

YesNo
Please rate your stress level*

LowMediumHigh
WOMEN CLIENTS

About birth control:

Avoid low-estrogen birth control pills, Norplant, Provera, and Depo-Provera if you are acne-prone. Premarin progesterone hormone replacement can also be problematic. If you have polycystic ovaries, they will cause hormonal changes and breakouts. Taking birth control pills can delay the onset of acne, and once you decide to stop taking them, you may experience the acne you would have had before you took them. We call this method the "band-aid approach to acne."
Are you taking birth control? *

YesNoN/A
If yes, please specify
Are you pregnant or trying to become pregnant?*

YesNoRecently had a baby and am breastfeedingN/A
Any menopause issues? *

YesNoN/A
If yes, please specify
Are you undergoing any hormone replacement therapy? *

YesNo
MALE CLIENTS
What is your current shaving system? *

Razor / Wet shaveElectricN/A
Do you experience irritation from shaving?

YesNoN/A
Post-Treatment Care Instructions:
- Aerobic exercise and/or vigorous physical activity should be avoided for 48 hours.
- Direct sunlight exposure is to be avoided immediately following the treatment (including any strong UV light exposure and/or tanning beds).
- If some sun exposure cannot be avoided first apply a broad-spectrum sunscreen of SPF 30. Sunscreen (with a minimum SPF 15) should become part of your daily skincare regimen as the skin can potentially become more sensitized to the sun as a result of this treatment.
- Unless otherwise specified, in the evening following your treatment, cleanse your skin with a mild cleanser and water followed by a non-active moisturizer.
- Do not apply additional exfoliating ingredients/products the day of your service as over-exfoliation can result in irritation or further sensitivity.
- Consult your skin therapist before resuming topical treatments.
- Chemical peels or facial waxing can result in skin flushing/redness or slight skin flaking or sensitivity for up to 48-72 hours post-treatment.
- DO NOT peel, pick, rub, or scratch your skin at any time, whatsoever. This can potentially cause damage or compromise your results.
I have read the post care instructions and agree to adhere to them*

Yes
I agree and consent to having before and after pictures or videos taken for my skin journey. I understand that some photos, may be used for promotion and marketing / social media purposes. I fully understand that Skin & Massage Spa By Bella will never tag or mention my name or any relation to my identity to the public without my permission.

YesNo
Cancellation Policy*

I understand the reservation and cancellation policies at Skin & Massage Spa By Bella and understand if I fail to give 24 hour notice for appointments that I will be asked to pay full service fee/cancellation fee/or my deposit will be forfeited.
Please carefully read through and check each one of the choices below to continue with your treatment:*

I agree to not use any exfoliants or get another facial service done on myself within 7 days of my treatment with Skin & Massage Spa By Bella.I agree to not use tanning beds OR be in exposed sunlight without SPF for at least 48-72 hrs.I agree to treat my skin gently and let my esthetician know of any concerns I may have after the facial treatment.All of the information is true and accurate to the best of my knowledge. As the client, I take full responsibility for altering my service provider of any physical or mental condition which may affect my services or results. I understand that my treatment is therapeutic in nature and I will alert my service provider of any discomforts I may experience.I agree to all of the above statements are true and correct to the best of my knowledge.
As a Client, I fully understand that by signing this agreement I agree to all terms and conditions listed above. Signature*

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Skin & Massage Spa By Bella

3881 W 3500 S Suite #118

West Valley City, Utah 84120

skinandmassagespabybella@gmail.com

801-837-8304

www.skinandmassagespabybella.com
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New Client Skincare Consultation Form

Your Skin

Your Health