NEW Client Consult Form
Please fill out this form at least 2 days prior to your appointment time if you are a NEW client. If your form is not filled out in a timely manner, your appointment may be rescheduled since some contraindications may apply.
Name
*
First Name
Last Name
Birthday
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email
*
example@example.com
Phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
What kind of music would you like to enjoy while getting your treatment?
*
What do you consider your skin type to be?
*
Normal (small pores & no flakiness or dryness)
Dry (small pores on entire face)
Oily (large pores on entire face)
Combination (large pores in T-zone area & small pores on rest of skin
Acne
Sensitive
Rosacea
I am unsure
What services are you interested in? or what are your concerns?
*
Age management- fine lines/ wrinkles
Acne treatment/ management
Rosacea
Hyperpigmentation
Other- type your specified concern below
If you answered 'other', please specify your concern
How would you want your treatment to be?
*
Silent- seeking relaxation
Minimal talking- educational
Are you pregnant or lactating?
*
Yes
No
What is your current skincare regimen? Include both AM/PM. Be specific with each product names/ brands.
*
If you use any AHA/ BHA/ retinol or prescribed products, please provide product name and information I need to know. If you aren't taking any, put N/A
*
How committed are you with your skincare goals?
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I am very committed and willing to do whatever it takes to reach my goals
I want to start incorporating routinely facials
I just get facials whenever I feel it's time to get one
I want at least a good skincare regimen
If other, type it below
If you answered other above, type your response here
In order to see results, home care regimens are CRUCIAL (80% of the results come from at home skin care regimens and 20% come from treatments). With that being said, what is your budget for skin care? (keep in mind product regimens RANGE FROM at $200-$350)
*
How would you want your skin care regimen recommendations to be?
*
Easy and short (1-4 steps)
4-5 steps
Full regimen (5+ steps)
Please list ALL medications, supplements, or herbal remedies you are currently taking:
*
Please list ALL allergies
*
What are your eating habits? Dairy?
*
Do you smoke? Please be honest
*
Yes
No
Do you use tanning beds?
*
List any surgeries or injuries you recently had:
*
Have you ever had professional treatments done in the past? If so, when was the last treatment and what treatment was it?- NOT including treatments done by DFW LUXE AESTHETICS.
*
Do you have any medical conditions? (Diabetes, thyroid, etc)
*
Do you wear SPF daily? (NOT INCLUDED IN MAKE UP)
*
Yes
No
Sometimes
Only in the summer
Have you previously been treated for a skin condition? If yes, please specify.
*
How did you treat the condition?
*
Dermatologist
Esthetician
Other
If you selected 'other', please specify
How did you hear about DFWLUXEAESTHETICS?
*
Instagram
Referral- write the name below
If you were referred by an existing client, please write their name here. Referrals give you 15% off your first INITIAL visit AND 15% off THEIR (referred person) NEXT visit.
I have NOT received any injectables, filler/ botox, laser hair removal, laser treatments in the past 14 days
*
I agree
If you disagree, please reach out so we can reschedule your appointment
If you are adding on DERMAPLANING- I understand the possible side effects include but are not limited to: skin tightness, mild to moderate redness, mild flaking, possible nicks. I also understand this procedure removes most, not all vellus hair (peach fuzz)
*
I agree
I disagree
Not getting this service- doesn't relate to me
I have stopped using all AHA/ BHA acids, exfoliating products containing retinoids 3-5 days before my treatment
*
I agree
If you disagree, please reach out so we can reschedule your appointment
I have NOT received any facial waxing/ threading/ hair removal within 72 hours
*
I agree
If you disagree, please reach out so we can reschedule your appointment
I have no viruses, such as colds, flu, fever, cold sores, warts, bacterial infections or fungal infections
*
I agree
If you disagree, please reach out so we can reschedule your appointment
I have no sunburns
*
I agree
If you disagree, please reach out so we can reschedule your appointment
I give Valerie and DFWLUXEAESTHETICS permission to take photos/ and or videos of me during my service to use for promotional purposes (some NOT ALL will be posted) and to keep track of my progress between treatments
*
I agree
I disagree
If you cancel/ reschedule your appointment with less than a 2 day notice from your appointment time, you LOSE your deposit. If rescheduling, you'll have to pay a new deposit for the new appointment. 24 hour and same day cancellations will be charged 100%. No call/ no show will be charged 100%
*
I agree
If you are 10mins+ late, unfortunately you will be charged an additional $10 and your service will have to be cut short to end on time. If you are 15mins late, your appointment will need to be rescheduled and you WILL BE CHARGED 100% of your total service.
*
I agree
If you fail to read my policies (above) before your appointment and have any contraindications and I am not able to perform your treatment, this may lead to reschedule or cancellation of your appointment and you will be charged 100% of your total service.
*
I agree
I understand, have read and completed this questionnaire truthfully. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received.
*
I agree
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
*
Submit
Submit
Should be Empty: