Bombshell Aesthetics
Client Consultation Form
Name
*
First Name
Last Name
E-mail
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Date
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Your Skin
What are your skin care goals?
*
What are your skin care challenges?
*
Acne/ Acne Scarring
Wrinkles/ Fine Lines
Hyperpigmentation/ Sun Damage
Redness/ Rosacea
Aging
Sensitivity
Melasma
Other
If "other", explain.
*
Have you ever had skin treatment before?
*
Yes
No
If so, explain.
What skin care products do you currently use?
*
Face Wash/ Cleanser
Face Scrub/ Exfoliant
Toner
Serum(s)
Moisturizer
Sunscreen
Eye Product(s)
Lip Product(s)
Other
Please type the brand name for each product you use.
Do you use Retin-A, Renova, Adapalene, Accutane, Differin, Gycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivatives? (Keep in mind that if you have used any form of retinol within the last 7 days, you will be ineligible to any facial service/ chemical peel.)
*
Yes, currently using.
Yes, but not within the last 7 days.
No.
Not sure.
Specify which product or type if you have answered "Yes, currently using" above.
Have you received any of these hair removal services in the last 7 days?
*
Waxing
Sugaring
Threading
Electrolysis/ Laser
Depilatory Cream
Shaving
None
Have you ever received chemical peels, laser services or microdermabrasion treatments?
*
Yes, within the last month.
Yes, within the last 2-3 months.
No.
Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks?
*
Yes
No
Back
Next
Your Health
Have you experienced any of these health conditions in the past or present?
*
Hormone Imbalance
Cancer/ Systemic Disease
High Blood Pressure
Diabetes
Heart Problem
Arthritis
Auto-Immune Disorders
Asthma
Epilepsy/ Seizure Disorder
Fever Blisters
Herpes
Frequent Cold Sores
HIV/AIDS
Lupus
Depression/Anxiety
Hepatitis
Headaches/ Migraines
Other
None
If you checked yes to any of these please provide further information. If not, mark N/A.
*
Do you?
*
Wear contact lenses.
Have a pacemaker.
Have metal implants.
Have body piercings.
No, not applicable.
Do you take any of the following dietary/ health supplements?
Multivitamin
Vitamin C
Vitamin D/D3
Zinc
Omega 3/ Fish Oil
B Complex/ B12
Garlic
Folic Acid
Melatonin
Coenzyme Q10
Biotin
Other
None
If other, please list
Any known allergies?
*
Aspirin
Tree Nuts
Latex
Dairy
Fruits
Vegetables
Shellfish
Iodine
Fragrances/ Essential Oils
Other
None
If other, please specify
Have you ever used or been prescribed any medications for acne/ acne control?
*
Yes
No
If yes, please specify what and last date used.
Are you a smoker?
*
Yes
No
Do you drink more than 4 caffeinated beverages a day?
*
Yes
No
Have you ever experienced claustrophobia?
*
Yes
No
Rate your stress level
*
Low
Medium
High
Back
Next
Female Clients
Are you taking birth control?
*
Yes
No
N/A
If "yes", what kind?
Are you pregnant or trying to become pregnant?
*
Yes
No
Recently had a baby and breast-feeding
N/A
Any menopause issues?
*
Yes
No
N/A
If "yes", please specify
Are you undergoing any hormone replacement therapy?
*
Yes
No
If yes, please specify
Male Clients
What is your current shaving system?
*
Razor/ Wet shave
Electric
N/A
Do you experience irritation from shaving?
*
Yes
No
N/A
Back
Next
How did you hear about me?
*
Website or Online Search
Instagram/ Facebook/ Twitter
Yelp
Referral
Other
Cancellation Policy
This policy has been established to help us serve you better. We always aim to provide excellent service to all our clients. In order to do so, we have our late arrival/cancellation & "no-show" policy. Late cancellations and no-shows leave gaps in our schedules that cannot be filled without timely notice that prevent us from being able to accommodate other clients on our wait-list. In the event that you need to cancel or reschedule your appointment with us, we request you to please contact us at least 24 hours in advance. Arriving late for your appointment: We will always try our best to accommodate if you are running late for your appointment, however this is not always possible without impacting on other appointments. If you arrive more than 10 minutes late for your scheduled appointment, we may need to cut your treatment short or it is considered 'no-show' and you will be charged a fee of $50. Non-arrivals/ No-show:A “no-show” is missing a scheduled appointment. If you miss a scheduled appointment without contacting us within the required time, it is considered 'no-show' and you will be charged a fee of $50. Please note that any pending charge will need to be settled before any further appointments can be booked with us. We understand that unavoidable issues come up and will do our best to work with you in case of an emergency, etc. However, If appointments are repeatedly missed or cancelled/rescheduled at late notice and become a habit, we may ask for full payment upfront at the time of booking to secure any future appointments. If you have any questions regarding this policy, please let us know and we will be glad to clarify any questions you have. Thank you, for your continued support of our efforts to deliver the best service to you.
*
I have read and fully understand the Appointment Cancellation Policy and I accept all above terms explained. I also agree to pay the cancellation fee in the event of a missed appointment.
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 this skin care professional from liability and assume full responsibility thereof.
*
Yes
Signature
*
Submit Form
Submit Form
Should be Empty: