• New Client Facial 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 Renew Therapies to:*

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

    OMY Esthetics

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