New Client Consultation Form

New Client Facial Treatment Consultation Form

The following information will be used to help plan a safe and effective treatment. Please answer the questions to the best of your knowledge. All information will remain private & confidential.
Today's Date

MonthDayYear
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
Emergency Contact Name & Mobile
How did you hear about me?
If Referral, please list name
If Other, please let me know
Your Skin
What are your skin care goals?
What are your skin care challenges?
Please feel free to go into more detail
Have you ever had a facial or skin treatment before?
If Yes, when?
Do you have a nickel sensitivity (need to know for dermaplane services)?
What Skin Care Products do you currently use?
Preferred Brand(s)
Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?
Please specify which product or type, if you answered 'Yes, currently using' to above.
A few days your appointment, please stop any use of products with any active ingredients or any exfoliation.
Have you received any of these facial services in the last 30 days?
If yes, please confirm last date

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

Other
If you checked yes to any of these please provide further information. If not mark N/A
Do you?
Do you take any dietary / health supplements?
If yes, please list
Any known allergies (eg: aspirin, latex, nuts, essential oils, cosmetic ingredients)?
If yes, please give details
Have you currently taking any prescription / over the counter medications
If yes, please give details
Are you a smoker?
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)
Do you drink alcohol
What is your daily water intake (glasses / litres)
Have you ever experienced claustrophobia?
Please rate your stress level
FEMALE CLIENTS
Are you taking birth control?
If yes, what kind
Are you pregnant or trying to become pregnant?
Any menopause issues?
If yes, please specify
Are you undergoing any hormone replacement therapy?
If yes, please specify
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.
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 25% of the service booked. As well if running 10 minutes late or more, my appointment may be cancelled. Suspected Covid-19/sickness is the exception to this rule, but please do let me know asap
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.

Other
Signature
Thank you for taking the time to complete this form - I look forward to giving you a facial.

Cameron
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New Client Facial Treatment Consultation Form

Your Skin

Your Health