Client Consultation Form

Client Consult Form
Thank you for booking with Beauty By Gerda Esthetics. Please fill out your form at least 48 hours prior to your appointment. Please be aware that your appointment may be rescheduled if any contraindications apply. Please read all policies before submitting your form.

PLEASE ONLY FILL OUT THIS FORM IF YOU ALREADY HAVE AN APPOINTMENT SCHEDULED WITH ME. THANKS, SEE YOU SOON♡.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Birthday*

MonthDayYear
Date
How did you hear about Beauty By Gerda Esthetics?*
How would you describe your skin type?

NormalDryOilyComboNot sure
What are your skin concerns? Choose any that apply.*

Dehydrated skinFine lines and WrinklesAcneSun damage or melasmaSensitive (Sensitized) skinTextureNeed a good skin glowDry, flakey patchesRosaceaScarringOther
Have you ever had a facial before?*

YesNo
Are you claustrophobic?*

YesNo
What is your current home regimen?*

I have a routine that works for me.I try different products every few months.I don't feel like my products are working for me.I don't know much about skincare.I need a new regimen.
Are you pregnant?*

YesNoN/A
Do you wear sunscreen daily? (not included in makeup)*

YesSometimesOnly in the summerNoYes it's in my moisturizer/foundation
Do you have any allergies or sensitivities?*
Do you have any medical conditions? (Epilepsy, Diabetes, Thyroid, etc.) *
Do you have metal implants, piercings ( on face) or pacemaker? *
Do you have any skin diseases/disorders that have been diagnosed by a doctor? Please explain.*
List any supplements/medications you take regularly? (prescription/otc)*
Have you received chemical peels, microdermabrasion, dermaplaning, laser, or any other resurfacing treatments in the last 3 months? Please specify treatment and how long ago ( FACE ONLY)*
List any skin or laser treatments, waxing on FACE only that you receive regularly .*
I have not received any injectables, filler/botox, laser hair removal, laser treatments in the last 14 days(minimum)*

I agree.If you disagree, please reach out to me to reschedule your appointment.
I have stopped all AHA/BHA acids, exfoliating products, and any products containing Retinoids 3-5 days before my treatment.*

I agree.If you disagree, please reach out to me to reschedule your appointment.
I have not received any facial waxing/threading/hair removal within 72 hours.*

I agree.If you disagree, please reach out to me to reschedule your appointment.
I have no viruses, such as colds, flu, fever, cold sores, warts, bacterial infections or fungal infections.*

I agree.If you disagree, please reach out to me to reschedule your appointment.
I have no sunburn or sun exposure without SPF.*

I agree.If you disagree, please reach out to me to reschedule your appointment.
I give Gerda with Beauty By Gerda Esthetics, permission to take photo and/or video of me during my service to use for promotional purposes and to keep track of my progress between treatments.*

I agree.I disagree.
If you cancel/reschedule your appointment with less than 48 hour notice, you will be charged 100% of your total service to the card on file.*

I agree.
If you fail to read my policies (above) before your appointment and have any contraindications and I am not able to perform your treatment, this may lead to reschedule or cancellation of your appointment and you will be charged 100% of your total service.*

I agree.
If applicable please don’t wear any make up to the appointment.*

I agree.Not applicable
If you are 10+ minutes late, unfortunately you will be charged an additional $10 and your service will be have to be modified to end on time. If you are 20+ minutes late, your appointment will need to be rescheduled and you will be charged 100% of your total service.*

I agree.
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 the technician/Esthetician/s.*

I agree.
Date*

MonthDayYear
Date
Signature*

Clear
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Client Consult Form

Thank you for booking with Beauty By Gerda Esthetics. Please fill out your form at least 48 hours prior to your appointment. Please be aware that your appointment may be rescheduled if any contraindications apply. Please read all policies before submitting your form.