Client Consultation Form

Name

First NameLast Name

Phone Number

Area CodePhone Number

Email

example@example.com

How did you hear about us?

What would you like to achieve from your treatment today?

MEDICAL HISTORY

Do you have any of the following conditions? If yes, please select them:

Rows
Cancer
Hypertension
Hypotension
Metal Implants
Pacemaker/Defibrillator
Diabetes
Heart Disease
Thyroid Disorder
PCOS/Hormonal Imbalance
Epilepsy/Seizures
Hepatitis A/B/C
HIV/AIDS
Other Contagious Disorder
Circulation Disorder
Blood Clots
Lupus
Immune Disorder
Eczema/Psoriasis
Migraines/Headaches
Depression/Anxiety
Other
N/A

YOUR SKIN

Have you ever had a facial treatment before?

Do you have any special skin problems or concerns pertaining to your face? If yes, please specify

Have you ever had chemical peels, laser or microdermabrasion? If yes, please specify when

Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products? If yes, please describe

Have you used any of the previously listed products in the last 3 months?

Have you used an acne medication?

When was the last time you used acne medication?

What acne medication have you used?

Have you recently used any self-tanning lotions, creams or treatments?

Current Skincare Routine (please list)

Rows	Name
Cleanser
Toner
AM Moisturizer
PM Moisturizer
SPF
Eye Cream
Serum
Mask
None

Area of Concern - SKIN:

Rows
Breakouts/Acne
Blackheads/Whiteheads
Oily/Shine
Redness/Rosacea
Broken Capillaries
Sun Spot/Liver Spot/Brown Spot
Uneven Skintone
Sun Damage
Wrinkles/Fine Lines
Dull/Dry Skin
Flaky Skin
Dehydrated Skin
Other
None

Areas of Concern - EYES:

Rows
Dehydrated/Dry
Wrinkles
Puffiness
Dark Circles
Other
None

Areas of Concern - LIPS:

Rows
Dry/Cracked Lips
Wrinkles/Fine Lines
Hyperpigmentation/Dark
None

Have you ever had an allergic reaction to any of the following?

Rows
Cosmetics
Medicine
Food
Animals
Sunscreens
Pollen
Alpha Hydroxy Acids
Fragrance
Shellfish
Latex
Drugs
Other
No Known Allergies

If Other, please list:

How often do you use SPF on your face?

Have you had any recent tanning bed or sun exposure that changed the color of your skin?

Do you spend extended periods of time exposed to the sun on a regular basis?

Have you experienced Botox, Restylane or Collagen injections?

Are you taking oral contraceptives?

Any recent changes to or from your contraceptive treatment?

Are you pregnant or trying to become pregnant?

Are you lactating?

Are you undergoing any hormone replacement therapy?

This question seeks to get your consent to use your photos/videos that are taken by your Esthetician. This gives us the permission to use your photos/videos for business purposes. Your answer to this question will not affect the services you receive today and/or any future appointments. Please select the ones you agree with:

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 at IISRAR Cosmetics Holitic Spa are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.

Signature

Date

Client Intake & Consent Form