Facial Client Consultation Form:
Thank you for the opportunity to support you in revealing your healthiest, glowing skin! Please fill out this brief consultation form.
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
*
example@example.com
Birthdate
*
-
Month
-
Day
Year
Date
How did you hear about us?
*
Please Select
Google
Facebook
Instagram
Yelp
Keough Chiropractic
Client Referral
Other
Other
Have you had facials before?
*
Yes
No
Date of last Dermatologist visit.
-
Month
-
Day
Year
Date
Skin Care Routine (Please check the boxes that apply to you on a daily basis)
*
Cleanse
Tone
Moisturize
Exfoliation
SPF
Other
Would you consider yourself to have sensitive skin?
*
Yes
No
If yes, to what and what kind of reaction does it cause?
What skin care line(s) do you use?
Are you sensitive to touch in any specific area?
Do you have tension or soreness in a specific area?
Any Allergies? (Check all that apply)
*
No Allergies
Shell fish (glucosamine)
Aspirin
Honey
Iodine
Nuts
Gluten
Other
Any other allergies we need to know about? What type of reaction does it cause?
Any prescription drugs, supplements or herbal remedies that could affect your skin?
*
No prescription drugs
I am taking Accutane
I am taking Antibiotics
I am taking blood thinners (anticoagulants)
I am taking medication that increases light sensitivity or phytotoxicity
Other
Please check any that apply:
*
None of the below
Any cardiac or circulatory problems?
Do you have high blood pressure?
Do you have arthritis?
Do you have frequent headaches?
Do you have epilepsy or seizures?
Other
Are you pregnant or nursing?
*
Yes
No
If pregnant how far along?
Do you get cold sores/fever blisters?
*
Yes
No
Any other medical conditions or previous medical conditions that could affect your skin or to be touched in a specific area (such as surgery, cancer, autoimmune disorders, etc)?
Have you had a medical cosmetic treatment within the past year?
*
No medical cosmetic treatments within the past year
I have had facial injections within the past 2 weeks (ex: botulinum toxin A such as Botox, Xeomin, or fillers such as Juvederm and Restylane).
I have had facial cosmetic surgery within the past year (face lift, neck lift, rhinoplasty, etc).
I have had a laser or IPL (Intense Pulsed Light) treatment, or a medical grade chemical peel within the past year.
Other
Are you currently using any cosmetic products that may contain the following substance? (Check all that apply)
*
None of the below
Retin-A or Retinoids
Renova
Differin
BHA or AHA
Glycolic, salicylic acid or Benzoyl peroxide
Anything else you'd like to share about yourself?
The body can store emotions in the muscles and vital energy point. The trapped energy can cause emotional and physical discomfort. Could there be an emotional component holding you back? Sometimes there may be an emotional piece causing muscle and nervous system tension.
PHOTO RELEASE: I give permission to Birch Botanical Spa to use and publish my photograph for educational and promotional purposes without compensation.
*
Yes
No
Your vibrant, healthy, glowing skin for life is our goal! With that in mind, please note the following: If my purpose for receiving treatments is to improve my health and the appearance of my skin, I agree to follow both the home care protocols and treatment schedule outlined for me by my Birch Botanical Spa practitioner. I acknowledge that Birch Botanical Spa services are not substitute for medical care, medical exams, or diagnosis. If I experience an unexpected reaction to a treatment, service or to a recommended skin care product, or have any questions about my prescribed home care regimen, I will contact Birch Botanical Spa expediently for guidance. 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 Birch Botanical Spa and/or professional from liability and assume full responsibility thereof.
*
Yes
No
Signature
*
Clear
Today's Date
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Month
-
Day
Year
Date
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