Consultation Consent Form

Consultation Form

Please answer the questions below to help us provide the best service for your skin.
Today's Date

MonthDayYear
DateHourMinutesAM/PM Option
Full Name*
Please type first and last name.
D.O.B. (MM/DD/YYYY)*
Phone*
Email Address*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about us?
your health
Within the last year, have you had any health problems that have affected or could affect your skin?

YESNO
If yes, please explain...
List any medications, supplements, vitamins, diuretics, slimming pills, oral contraceptives, isotretinoin, etc that you take regularly.
Do you have metal implants, a pacemaker, or body piercings?

YESNO
Do you have any allergies?

YESNO
If yes, please explain...
Do you have sinus problems?

YESNO
Have you experienced claustrophobia?

YESNO
Do you have active cold sores?

YESNO
your skin
What areas of concern do you have regarding your skin?

Breakouts/AcneBlackheads/WhiteheadsUneven Skin ToneSun DamageExcessive Oil/ShineWrinkles/Fine LinesDull/Dry SkinRosaceaBroken CapillariesRednessDehydratedSun, Liver, Brown SpotsMelasmaNone
What are specific concerns/challenges with your skin?
What type of skin do you have?

NormalOilyDryCombination
What skin care products are you currently using?

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

CosmeticsMedicineFoodAnimalsSunscreenDrugsIodinePollenAHAsFragranceShellfishLatexNone
Have you had chemical peels, microdermabrasion or any resurfacing treatments within the last 3 months?*

YESNO
Have you been waxed within the last 72 hours?*

YESNO
Do you currently or have you used in the last 3 months Retin-A, Renova, Adapalene, AHA's, or Retinol/Vitamin A derivative products?*

YESNO
Are you currently using any products that contain the following ingredients?

Glycolic AcidLactic AcidExfoliating ScrubsHydroxy AcidsNone
Please specify if any of the following apply to you:

pregnanttrying to become pregnantlactatingmenstruatingN/A
Have you received Botox, Restylane, or Collagen injections in the last 6 months?*

YESNO
This consultation form is completely confidential. Completion of the form gives the general state of health and assists our specialist in directing a customized course of treatment for your individual skin care needs. We will not provide this information to anyone else, except as required by law, and we will not sell this information to anyone. We may, however, contact you with product related information.
I confirm (to my best knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. I have been informed of and understand the contraindications to the requested treatments and agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liabilities toward my technician and the employer for any injury or damages incurred due to any misrepresentation of my health history. I also understand the post treatment home care instructions. I understand how important it is to follow all instructions given to me for post treatment care.
Client Signature*

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Consultation Form

your health

your skin