New Client Consultation Form

New Client Facial Treatment Consultation Form

BELLA Beauty BY LINDA
Today's Date*

MonthDayYear
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

City

Country
Phone Number*

PrefixPhone Number
E-mail*
Emergency Contact Name & Mobile
How did you hear about me?*

Website / Online SearchInstagramFacebookReferralOther
If Referral, please list name
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)
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
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
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 / MigrainesCovid-19OtherNone
Do you?*

Wear contact lensesWear hearing aidsNo, not Applicable
Do you take any dietary / health supplements?

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

YesNo
If yes, please give details
Have you currently taking any prescription / over the counter medications*

YesNo
If yes, please give details
Are you a smoker? *

YesNoSocial
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)*

YesNo
Do you drink alcohol*

YesNo
What is your daily water intake (glasses / litres)*
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
Any menopause issues? *

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

YesNo
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.
Reservation & Cancellation Policy for all current and future appointments: In the event of cancellations received less than 24 hours prior to appointment a cancellation fee equal to the reserved service booking will incur. No Shows will be charged 100%.*

I understand the reservation and cancellation policies at bella.lashesbylinda & Esthetic Service's and consent to my credit card on file being charged if I fail to give the required notice.
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.*

By selecting this box, I agree to liability.
Signature*

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

Linda
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New Client Facial Treatment Consultation Form

Your Skin

Your Health