New Client Consultation Form

Facial Treatment Consultation Form

The following information will be used to help plan a safe and effective treatment. Please answer the questions to the best of your knowledge. All information will remain private & confidential.
Today's Date

MonthDayYear
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

City

Country
Phone Number

PrefixPhone Number
E-mail
Emergency Contact Name & Mobile
How did you hear about me?
If Referral, please list name
If Other, please let me know
Your Skin
What are your skin care goals?
What are your skin care challenges?
Please feel free to go into more detail
Have you ever had a facial or skin treatment before?
If Yes, when?
What Skin Care Products do you currently use?
Preferred Brand(s)
Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?
Please specify which product or type, if you answered 'Yes, currently using' to above.
Have you received any of these facial services in the last 30 days?
If yes, please confirm last date

MonthDayYear
Date
Your Health
Have you experienced any of these health conditions in the past or present?
If you checked yes to any of these please provide further information. If not mark N/A
Do you?
Do you take any dietary / health supplements?
If yes, please list
Any known allergies (eg: aspirin, latex, nuts, essential oils)?
If yes, please give details
Have you currently taking any prescription / over the counter medications
If yes, please give details
Are you a smoker?
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)
Do you drink alcohol
What is your daily water intake (glasses / litres)
Have you ever experienced claustrophobia?
Please rate your stress level
FEMALE CLIENTS
Are you taking birth control?
If yes, what kind
Are you pregnant or trying to become pregnant?
Any menopause issues?
If yes, please specify
Are you undergoing any hormone replacement therapy?
If yes, please specify
Is there any other information you would like to make your therapist aware of? If yes, please give details:
Preferred essential oil
Post Facial Advice: 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. Facial massage, cupping and gua sha may cause temporary redness/pinking of the skin - this is a normal and positive outcome and indicates the increase of bloodflow as a result of the treatment. In areas of stagnation, cupping may cause skin markings which may last a few days, otherwise all pinking should subside within a few hours. If you have any concerns about this please let me know prior to the 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 exfoliating ingredients / products the day of your service as over-exfoliation can result in irritation or further sensitivity. If you have any concerns post treatment please contact me.
Reservation & Cancellation Policy for all current and future appointments: In the event of cancellations received less than 24 hours prior to appointment a cancellation fee of 50% of the service will be charged. No Shows will be charged banned from future booking. Suspected Covid-19 is the exception to this rule, but please do let me know asap. After 10 minutes of your reservation beginning, I reserve the right to cancel and charge full price if you have not shown and/or contacted me.
CLIENT DECLARATION: 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. I understand that redness and other reactions may occur from facial treatments. If I experience any discomfort during the treatment I will inform the therapist immediately, so that the products/techniques can be adjusted. The treatments I receive here are voluntary and I release the therapy from liability and assume full responsibility thereof.
GDPR Statement: In accordance with the General Data Protection Regulation, this information will be held securely by Spellbound Beauty Bar for 8 years. This is standard practice and is required for insurance purposes. Please note, your personal data will remain confidential and will never be shared with a third party without your written consent. If you wish to see the data on your files, please request in writing via email to spellboundbeautybar513@gmail.com. Please confirm that you have read and agree with this statement.
I occasionally contact clients to follow up on a session and I also send booking confirmation and a reminder via email / SMS. I occasionally send emails regarding company news, updates, special offers etc. You may unsubscribe from these marketing emails at any time. Please confirm you give your permission for Spellbound Beauty Bar to:
I consent to video for the purpose of documentation, potential advertising and promotional purposes.*
I consent to “before and after” pictures for the purpose of documentation, potential advertising and promotional purposes.
Signature
Thank you for taking the time to complete this form - I look forward to seeing you soon.

Dae'zha
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Facial Treatment Consultation Form

Your Skin

Your Health