• New Client Facial Treatment / 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.
  • Treatment Required

  • Today's Date*
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  • Date of Birth*
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  • How did you hear about me?*

  • Your Skin

  • What are your skin care challenges?*
  • Have you ever had a facial or skin treatment before?*
  • What Skin Care Products do you currently use?*
  • Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?*
  • Have you received any of these facial services in the last 30 days?*
  • If yes, please confirm last date
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  • Your Health

  • Have you experienced any of these health conditions in the past or present?*
  • Do you?*
  • Do you take any dietary / health supplements?
  • Any known allergies (eg: aspirin, latex, nuts, essential oils)?*
  • Have you currently taking any prescription / over the counter medications*
  • Are you a smoker? *
  • Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)*
  • Do you drink alcohol*
  • Have you ever experienced claustrophobia? *
  • Please rate your stress level*

  • FEMALE CLIENTS

  • Are you taking birth control? *
  • Are you pregnant or trying to become pregnant?*
  • Any menopause issues? *
  • Are you undergoing any hormone replacement therapy?
  • 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.*
  • I occasionally contact clients to follow up on a session and I also send booking confirmation and a reminder via email / SMS. I occasionally send emails regarding company news, updates, special offers etc. You may unsubscribe from these marketing emails at any time. Please confirm you give your permission for The Deluxe Touch London to:*

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

    Melissa

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