New client form

1
Name* This field is required.
First Name
Last Name
2
Phone Number* This field is required.
Area Code
Phone Number
3
Email* This field is required.
example@example.com
4
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
How would you describe your skin type? Check all that apply* This field is required.
Oily
Dry
Normal
Sensitive
Combo
Other
6
What are your skin care concerns? Check all that apply* This field is required.
I experience a lot of breakouts
I get pimples here and there
My nose looks like it has a lot of blackheads
I would like to plump fine lines and wrinkles
I would like to remove my peach fuzz
I want my skin brighter/even toned
I have sun damage
My skin feels greasy all the time
I have acne scarring
Everything I use irritates my skin
My skin feels dull
My skin feels congested
I want my skin to feel smoother
My skin turns red easily
7
What is your current relationship with skin care?* This field is required.
I love trying different products all the time
I have a routine that works for me
I don’t feel like my products are working for me
I don’t know much about skincare
8
Have you been under the care of a dermatologist within the past year if so what for?* This field is required.
9
Do you currently use Accutane, Retin-A, or any other prescription skincare products? Please specify.* This field is required.
10
Have you received any injectables such as Botox, Juvederm, Dysport,Restylane,etc? If so please specify treatment and how long ago * This field is required.
11
Do you have any skin disease/disorders that have been diagnosed by a doctor? Please specify* This field is required.
12
Have you received chemical peels, microdermabrasion,Dermaplane,or any other resurfacing treatments? Please specify treatment and how long ago.* This field is required.
13
Do you have any metal implants, pacemaker, or piercings? Please specify.* This field is required.
14
Do you have any allergies or sensitivities? Please specify.* This field is required.
15
List any medications you take regularly.* This field is required.
16
Are you pregnant, lactating or trying to become pregnant?* This field is required.
17
List any skin treatments, waxing, lazer, etc, that you receive regularly.* This field is required.
18
List any dietary restrictions.* This field is required.
19
Do you smoke/drink alcoholic beverages/consume caffeine regularly? Please specify * This field is required.
20
Do you play sports or workout regularly?* This field is required.
Yes
No
21
Do you wear makeup regularly?* This field is required.
Yes
No
22
Do you tan regularly indoors or outdoors?* This field is required.
Indoor
Outdoor
I don’t tan
23
Do you wear sunscreen regularly?(not included in makeup)* This field is required.
Yes
No
24
List all skincare products and brands you are currently using (cleansers, exfoliants, toners, serums, moisturizers, oils, masks, spf, tools, etc.) please specify. * This field is required.
25
How often are you using your skincare products?* This field is required.
Morning only
Night only
Morning and night
Neither
26
Are there any treatments you’d like more info on?* This field is required.
Sugar/waxing hair removal
Lash lift
Nanoneedling infusion
Other
27
How did you hear about Skin by Icy?* This field is required.
Referral
Instagram
Facebook
Google
Other
28
I give Skin by Icy permission to take photo and/ or video of me during my service to use for promotional and educational purposes, as well as to keep track of my progress between treatments.* This field is required.
I agree
29
If I experience any pain or discomfort during the session I will immediately inform my Skin by icy specialist so that the session may be adjusted to my level of comfort I further understand that aesthetic treatments should not be considered a substitute for medical examination, diagnosis or treatment, that I should see a physician or other qualified medical specialist for any mental or physical alignment that I am aware of I understand that licensed estheticians are not qualified to diagnose, prescribe or treat any physical ot mental illness, and nothing in the course of the session should be constructed as such, because certain esthetic treatments should not be performed under certain medical conditions, I affirm that I have stated all my non-medical conditions and answered all questions honestly.I agree to keep the Skin by Icy updated as to any changes in my medical profile,and I understand that there shall be no liability on the Skin by icy specialist as I should fail to do so.* This field is required.
I agree
30
Date* This field is required.
Date
Month
Day
Year
31
Signature* This field is required.
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