Skin Care Consultation Form
Name
First Name
Last Name
Birth Date
Please select a month
January
February
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Month
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Day
Please select a year
2024
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Year
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you hear about us?
Website / Online Search
Social Media
Referral
Other
If referral, please list name
Back
Next
Are you allergic to anything?
Yes
No
Please list your allergies
Have you ever had a facial or skin treatment before?
Yes
No
If yes, what type & when?
Have you been under the care of a detmatologist?
Yes
No
If yes, please provide more information
Do you have a history of acne?
Yes
No
If yes, are you using or have you ever used any medications for acne?
Yes
No
Name of medication:
Do you sunbathe or participate in outdoor activities?
Yes
No
Have you ever had a reaction to any skin care product or cosmetic?
Yes
No
If yes, please provide more information
What type of skin do you think you have?
Oily
Combination
Dry
Normal
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Next
What conditions would you like to improve?
Acne
Oily Skin
Dry Skin
Bumps
Large Pores
Malesma
Redness
Brown Spots
Sun Damage
Milia
Sagging Skin
Rosacea
Lines & Wrinkles
Healthy Aging
Age Management
White Spots
Scarring
Keratosis Pilaris
Hyperpigmentation
Hypopigmentation
Other
Please tick any ingredients you are currently using or have used:
Retinol
Benzoyl Peroxide
Adapalene
Glycolic Acid
Hydroquinone
Azelaic Acid
Salicylic Acid
Tretinoin Isotretinoin (Accutane)
Citric Acid
Topical Antibiotics
Resorcinol
Topical Steroids
Other
Have you had any of the following? (Tick all that apply):
Chemical Peels
Extractions
Laser Resurfacing
Light Treatments
Electrolysis
Facial Cosmetic Surgery
Microdermabrasion
Laser Hair Removal
Facial Injectibles
Dermaplanning
Waxing
Other
What are your skin care goals?
What skin care products do you currently use?
Check if you are using a product
Brand Name
Product Name
Any thoughts?
Cleanser / Face Wash
Bar Soap
Face Scrub / Exfoliants
Toner
Serums
Moisturizer
Sunscreen
Eye Product(s)
Lip Product(s)
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Next
Are you currently taking any medications?
Yes
No
If yes, please provide more information
Are you on hormone-replacement therapy?
Yes
No
Are you on birth control pills?
Yes
No
Are you pregnant or breastfeeding?
Yes
No
Date
-
Month
-
Day
Year
Date
Client Siganture
Submit
Submit
Should be Empty: