New Client Skincare Appointment Request
If Question does not apply, please leave blank.
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Are you over the age of 18? (Minor clients will be required to have electronic release form to be completed by parent/guardian.
Yes
No
How do you prefer to be contacted?
Please Select
Text message
Phone call
Email
Have you ever recieved a facial service?
Yes
No
In the past 3 months have you received a facial skin treatment (laser, microneedling, chemical peel, etc.) or cosmetic surgical procedure? If so, what type?
For what reasons are you seeking skincare/facial services (check all that apply)?
Anti-aging
Hyperpigmentation
Acne/Congested Skin
Dry Skin
Exfoliation
Lymphatic Drainage
Dermaplane
Relaxation
Other
If "other", please briefly explain.
Are you currently/regularly using any of the following (check all that apply)?
Prescription Retin A/Tretinoin
Retinol (over-the-counter)
Accutane
Hydroquinone
None
Do you currently have (or are being treated for) any of the following conditions (check all that apply)?
Cancer
Diabetes
Pregnant or Nursing
High or Low Blood Pressure
None
Please list any allergies:
Are you sensitive to any smells or essential oils? Please list.
Use this space to describe any skin or health conditions, or any other information that you believe would be relevant.
What days/times work best for your appointment?
Who may I thank for referring you?
Submit
Should be Empty: