New Client Consultation Form

New Client Consultation Form

Please make sure your information is correct!
Name

First NameLast Name
Date

MonthDayYear
Date
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
How did you hear about us?

Other
If referred, who from?
Your Skin
Have you ever had a facial or skin treatment before?
What are your skin goals?
Skincare concernse?

Other
What would you say your skin type is?
What Skin Care Products do you currently use? *
Do you experience routine breakouts or acne? *
Have you been diagnosed with any of the following? *
Have you ever received chemical peels, laser services, or microdermabrasion treatments? *
Have you received any of these facial hair removal services in the last 7 days? *
Do you currently use:
Are you currently using any products that contain:
Do you?
Your Health
Have you experienced any of these health conditions in the past or present? *

Other
Any known allergies? *

Other
Have you ever received any botox or fillers? If so, when?
Especially in the last two weeks!
List any medications/supplements you are taking.
Have you ever experienced claustrophobia? *
Please rate your stress level *
Are you taking birth control? *
Pregnancy *
I understand that my skin may experience temporary irritation, tightness, redness, or slight swelling, which typically resolves within 72 hours depending on my skin sensitivity.

I acknowledge that if I have allergies to any ingredients in the products used, I may experience allergic reactions.

I understand that without using a minimum of SPF45 sunscreen, I am more prone to sunburn, skin damage, and hyperpigmentation. Therefore, I should avoid prolonged sun exposure.

I acknowledge that this treatment is a voluntary cosmetic procedure, and no medical claims have been made or implied.

I understand that I should refrain from using Retin-A products, engaging in aggressive exfoliation, waxing, or using products containing acids that are not part of the recommended take-home regimen for a period of 2-4 weeks following the treatment.
I have read the post care instructions and agree to adhere to them *
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 Morning Glow and its staff from liability and assume full responsibility thereof. *
I use social media platforms for promotional purposes. Are you okay with me taking photos/videos during your service? *
Signature
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New Client Consultation Form

Your Skin

Your Health