New Client Consultation Form

Lafrance Aesthetics New Client Consultation Form
Date*

MonthDayYear
Name*

First NameLast Name
Date of Birth*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

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

Website / Online SearchYelpFacebookReferralOther
If Referral, please list name
If Other, please let me know
To get started with Lafrance Aesthetics, which consultation are you looking to receive? All clients must begin with a consultation to discuss homecare and treatment plan. Are you looking for an appointment for in clinic treatment, virtual consultation, virtual acne bootcamp?

New Client Consultation + TreatmentVirtual ConsultationVirtual Acne Bootcamp
Which treatments are you interested in receiving after consultation is complete? (refer to main website for details and pricing on treatments) Keep in mind that all treatment plans require prep with a tailored home care routine. We will not perform any treatments if it is unethical to do so.

Custom TreatmentAcne bootcampGlacial TreatmentHydrafacialDmk Enzyme TherapyChemical Peels (Medical Grade + Custom)Hydrafacial KeraviveMicroneedlingLiquid Microneedling
Are you looking to make treatments a monthly / regular thing in order to meet your goals?*

Yes, I am ready for a new homecare regimen and to come in for monthly or frequent treatmentsNo, I just want a new home care routine
What is your anticipated investment for your home care routine? Please note that a customized regimen typically starts at $175. With over 100+ products in our range, we’re able to accommodate a variety of budgets. Our priority is to ensure that your results and home care plan are both effective and easily accessible.

$175-$200$250-$350$350+I am willing to invest whatever it may be to get started on a quality and results driven treatment plan + regimen.I am currently on a professional homecare routine from my last esthetician and would like help making adjustments.
Your Skin
What are your skin care goals? *
What are your skin care challenges?*

Wrinkles / Fine LinesHyperpigmentation / Sun DamageAcne / Acne ScarringRedness / RosaceaAgingMelasmaSensitivityOther
Please feel free to go into more detail. The more information the better, so we can come up with a curated plan for you.*
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)
To help us tailor the best skincare plan for you, please upload a photo of your current skincare routine, along with the order in which you use your products. This will give us a clearer understanding of your routine and allow us to make the most effective recommendations.
"Please provide details on the specific products you're currently using (including brand and product name/type). This will help me address any ingredient-related questions and guide you toward your skincare goals."
Cleanser / Face Wash
Bar Soap
Face Scrub / Exfoliants
Toner
Serums
Moisturizer(s)
Sunscreen
Eye Product(s)
Lip Product(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 hair removal services in the last 30 days?*

WaxingSugaringThreadingElectrolysis / LaserDepliatory CreamShavingNone
If checked, please note last time.
Have you ever received chemical peels, laser services, or microdermabrasion treatments? *

Yes, within the last monthYes, within the last 2-3 monthsNo
Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks?*

YesNo
Your Health
Have you experienced any of these health conditions in the past or present?*

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*
Do you?*

Wear contact lensesHave a pacemakerHave metal implantsHave body piercingsNo, not Applicable
Do you take any of the following dietary / health supplements?

MultivitaminVitamin CVitamin D/D3ZincOmega 3 / Fish OilB Complex / B12GarlicCalciumFolic AcidMelatoninCoenzyme Q10BiotinOther
If other, please list
Any known allergies?*

AspirinTree NutsLatexDairyFruitsVegetablesShellfishIodineFragrances / Essential OilsOtherNone
If Other, please specify
Have you used or been prescribed any medications (topical or oral) for acne / acne control?*

YesNo
If yes, please specify what and date last used
Are you a smoker? *

YesNoSocial
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
Please let me know if you would like to learn about natural ways to lower stress levels
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
Any menopause issues? *

YesNoN/A
If yes, please specify
Are you undergoing any hormone replacement therapy?

YesNo
If yes, please specify
MALE CLIENTS
What is your current shaving system? *

Razor / Wet shaveElectricN/A
Do you experience irritation from shaving? *

YesNoN/A
Post Facial Care/Waxing Instructions: Aerobic exercise and/or vigorous physical activity should be avoided for 48 hours. 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. Sunscreen (with a minimum SPF 15) should become part of your daily skin care regimen as skin can potentially become more sensitize to the sun as a result of this 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 additional exfoliating ingredients/products the day of your service as over-exfoliation can result in irritation or further sensitivity. Consult your skin care professional before resuming topical treatments. Enzyme peels, chemical peels or facial waxing can result in skin flushing/redness or slight skin flaking or sensitivity for up to 48-72 hours post treatment. DO NOT peel, pick, rub, or scratch your skin at any time, whatsoever. This can potentially cause damage or compromise your results.*

I have read the post care instructions and agree to adhere to them.
Your appointments and well-being are very important to us. We understand that sometimes, unexpected delays can occur, making schedule adjustments .Any cancellation or reschedule made less than48 hours will result in a cancellation fee. If you are more than 15 minutes late for your service, we may not be able to accommodate you. In this case, the same cancellation fee will apply. We will do our very best to reschedule your service for another time that is convenient to you. We also require a credit card to hold your appointment.. Cancellation fees will be charged to your card on file.*

I have read and agree to the cancellation policy and agree to pay cancellation fee in the event a cancellation is made in less than 48 hours.
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
photography release*
Product Notice*
Products Notice Products once they have left the clinic cannot be returned. If you have a defective product or damaged product from shipping please bring it in clinic so we may exchange it with the company.
Refund policies
All services rendered at Lafrance Aesthetics are nonrefundable.
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Lafrance Aesthetics New Client Consultation Form

Your Skin

Your Health