New Client Consultation Form

Client Facial Treatment 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
Phone Number*

PrefixPhone Number
E-mail*
How did you hear about me?*

Website / Online SearchInstagramFacebookReferralOther
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?*

Wrinkles / Fine LinesHyperpigmentation / Sun DamageAcne / Acne ScarringRedness / Rosacea / SensitivityAgingBreakoutsDry / FlakyExcess OilOther
Please feel free to go into more detail
Have you ever had a facial or skin treatment before?*

YesNo
If Yes, when?
What Skin Care Products do you currently use?*

Cleanser / Face WashBar SoapFace Scrub / ExfoliantsTonerSerumsMoisturizerSunscreenEye Product(s)Lip Product(s)
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?*

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 received any of these facial services in the last 30 days?*

WaxingSugaringThreadingElectrolysis / LaserDepliatory CreamBotox / Dermal Fillers / Facial InjectiblesNone
If yes, please confirm last date

MonthDayYear
Date
Your Health
Do you take any dietary / health supplements?

YesNo
If yes, please list
Any known allergies (eg: aspirin, latex, nuts, essential oils)?*

YesNo
If yes, please give details
Are you currently taking any blood thinners?*

YesNo
If yes, what name and strength?
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
FEMALE CLIENTS
Are you taking birth control? *

YesNoN/A
If yes, what kind
Are you pregnant or trying to become pregnant?*

YesNoRecently had a baby and am breastfeedingN/A
Are you undergoing any hormone replacement therapy?

YesNo
If yes, please specify
Is there any other information you would like to make your therapist aware of? If yes, please give details:
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.*

I have read the post care instructions and agree to adhere to them.
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.*

I have read and agree.
Signature*

Powered by Jotform SignClear
Thank you for taking the time to complete this form - I look forward to seeing you soon.

Ranee
Should be Empty:

Client Facial Treatment Form

Your Skin

Your Health