Facial Consultation Form

Facial Consultation Form
General Data
Legal Name*

First NameLast Name
Preferred Name

First NameLast Name
Pronouns
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Profession
18-2525-3536-4546-5556+
YesNo
1x month2x month1x every 3 month1 or 2x year (irregularly)
Your Health

This information is to ensure we carry out the appropriate treatments for you, taking into consideration any medical conditions which might have treatment contraindications.
PregnancyHeart conditionDermatitisMenopauseEczemaDiabetesHeadaches/migrainesHigh blood pressureAsthmaEpilepsySkin cancerThyroid - hyper or hypoPsoriasisRosaceaWater retentionVaricose veinsOther medical condition
Are you taking any medications?
Do you suffer from any allergies?
Do you suffer from claustrophobia?
Your Lifestyle
How would you describe your stress levels from 1-10?

1

2

3

4

5

6

7

8

9

10

1 is Low, 10 is High
Everyday3x a week1x a weekNever
BalancedOn the runVery unbalanced
YesNo
YesNo
DailyOccasionallyNever
1x day2x dayMore than 2x day
Your Face
NormalDryOilyCombination
Spots & pimplesGeneral dullnessWrinklesAcneOilinessLack of toneHyper-pigmentationDilated poresScarringSun exposureSensitivityUnder-eye puffiness or dark circlesDehydration
What would you like to achieve from your treatment today?
Eye areaFaceDécolletéHands
Chemical peelsRetinol based productsLaser resurfacingBotoxOther
CleanserDay moisturizerSoapNight moisturizerTonerSunscreenEfoliatorSerum/concentrate/boosterMaskEye creamOther
What is your primary concern?
Your Body
WeightDry skinLoss of toneCelluliteMuscle toneStretch marksElasticityBust area - lack of toneVaricose veins/broken capillariesDry handsDry feetHeavy legs
Body scrubBody moisturizerCellulite productsBust productsHand creamFoot cream
What is your primary concern?
What would you like to achieve from your treatment today?
Privacy Statement

The skincare history and health information you have provided is used to help our therapists recommend skin care treatments and home care products that are suitable for your skin and condition. It is accessible to authorized staff for that purpose only and may be accessed by you at any time.
Name

First NameLast Name
Date

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Date
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Facial Consultation Form

General Data

Your Health

Your Lifestyle

Your Face

Your Body