New Client Consultation Form

New Client Skin Consultation Form

Please answer a few questions about your skin conditions and preferences so we can tailor the service that are customized for your skin needs.
Date*

MonthDayYear
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
E-mail*
Website / Online SearchYelpFacebookReferralOther
If Other, please let me know
Your Skin
NormalOilyCombinationDrySensitiveOther
Below 2020-2627-3535-50Above 50
What are your skin care goals? *
Wrinkles / Fine LinesHyperpigmentation / Sun DamageAcne / Acne ScarringRedness / RosaceaAgingMelasmaSensitivityOther
Please feel free to go into more detail
YesNo
If Yes, when?
Cleanser / Face WashBar SoapFace Scrub / ExfoliantsTonerSerumsMoisturizerSunscreenEye Product(s)Lip Product(s)
If you are seeking corrective treatments please detail the SPECIFIC products (BRAND & PRODUCT TYPE/NAME) you are currently using so I can best answer any questions on ingredients and help you meet your skin care goals.
Cleanser / Face Wash
Bar Soap
Face Scrub / Exfoliants
Toner
Serums
Moisturizer(s)
Sunscreen
Eye Product(s)
Lip Product(s)
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.
WaxingSugaringThreadingElectrolysis / LaserDepliatory CreamShavingNone
If checked, please note last time.
Yes, within the last monthYes, within the last 2-3 monthsNo
YesNo
Your Health
Hormone ImbalanceCancer / Systemic DiseaseHigh Blood PressureDiabetesHeart problemArthritisAuto-Immune DisordersAsthmaEpilepsy / Seizure DisorderFever BlistersHerpesFrequent Cold SoresHIV/AIDSLupusDepression/AnxietyHepatitisHeadaches / MigrainesOtherNone
If you checked yes to any of these please provide further information. If not mark N/A*
MultivitaminVitamin CVitamin D/D3ZincOmega 3 / Fish OilB Complex / B12GarlicCalciumFolic AcidMelatoninCoenzyme Q10BiotinOther
If other, please list
AspirinTree NutsLatexDairyFruitsVegetablesShellfishIodineFragrances / Essential OilsOtherNone
Always BurnUsually BurnSometimes BurnRarely BurnNever Burn
If Other, please specify
YesNo
If yes, please specify what and date last used
YesNoSocial
YesNo
LowMediumHigh
FEMALE CLIENTS
YesNoN/A
If yes, what kind
YesNoRecently had a baby and am breastfeedingN/A
YesNoN/A
If yes, please specify
YesNo
If yes, please specify
MALE CLIENTS
Razor / Wet shaveElectricN/A
YesNoN/A
Please upload a photo of your current skin problems without any filters or makeup.*

Browse Files

Cancelof
I understand the reservation and cancellation policies and consent to being charged if I fail to give 48 hour notice for appointments scheduled. Our Refund Policy, once the service has been completed, no refunds will be issued.
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 skin care professional from liability and assume full responsibility thereof.

Yes
The treatment has been explained to me, and I have had the opportunity to ask questions. The effect and nature of the treatment to be given, as well as possible alternative methods of treatment, have been fully explained to me. I am advised that though good results are expected, they CANNOT and are not GUARANTEED to be effective. I agree to actively participate in the instructions and home care procedures and to read all the documentation given regarding the products and treatment before and after care instructions. I hereby acknowledge that all the information in this document is correct and I have left nothing out. I acknowledge that there is no guarantee that dark discolouration of skin will be reduced or fade. Pigmentation may improve or darken with successive treatments. I acknowledge that my skin may experience temporary irritation, tightness and redness. I acknowledge that if I fail to use minimal sunscreen (SPF 30), I am more susceptible to sunburn, skin damage and hyperpigmentation. I understand that I may be required to have photographs taken before and after treatments for my medical records I hereby acknowledge and agree to hold the Salon, and/or Professional, and/or Jaluxury harmless against any adverse reaction which could be sustained during or as a result of the products prescribed.*

Yes
TRANSITIONAL PERIOD is normal, temporary skin condition that may occur due to the introduction of specific active ingredients that have a positive effect on the function and structure of the skin. When starting with a new range of active products you may experience a transitional or crisis period. TYPICAL SYSTEMS THAT MAY BE EXPERIENCED: - Excessive oiliness- Excessive dryness or slight flakiness- Breakouts and/or underlying congestion - Increased sensitivity - Hyperpigmentation and capillaries may appear more visible due to the treatment process.*

Yes
Signature*
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New Client Skin Consultation Form

Your Skin

Your Health