Facial Client Consultation Form

CLIENT CONSULTATION

New and Returning Clients:
Thank you for booking your facial treatment with me, Ashlee Tomlin!
I'm looking forward to seeing you!

Please fill out this Client Consultation form prior to your appointment to ensure all information is current. This will allow time to review your answers and reach out if there are any contraindications that could affect your service.

Please Note: All information that is shared in the Client Consultation form will remain confidential to protect your privacy and comfort.

Thanks again, see you soon!

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number incase your service provider need to reach you.Format: (000) 000-0000.

What age group do you fall under?

How did you hear about me?

HEALTH CHECK: Currently have no viruses such as COVID, the Flu, a Cold, a Fever, Cold Sores, Warts, or Bacterial Infection. If my health changes before or on the day of my appointment, I will reach out to the Esthetician, Ashlee Tomlin (@amtskin), about rescheduling.

Have you ever been to an Esthetician or a Dermatologist before?

How long ago was your last visit?

How would you describe your skin type?

What are your current TOP 3 skin concerns and what improvements would you like to see?

How do you feel about your current skin care routine?

Do you currently use any skincare products that contain active and/or exfoliating ingredients? Example: Glycolic Acid, Salicylic Acid, Benzoyl Peroxide, Lactic Acid, Retinol, etc.

To maintain the integrity of your skin, it is important to stop all active and/or exfoliating products 3 days prior to your scheduled facial appointment. Please select "I agree" to confirm you have stopped all active and/or exfoliating products prior to your appointment.

Are you taking or have you taken acne medication before?

Are you still taking your acne medication? If you answered yes: Acne medication can make a person's skin extremely sensitive while in use. If you are currently on any acne medication OR you stopped but haven’t been off it for at least 6 months, your requested facial will need to be altered or postponed to ensure the safety of your skin.

Can you please list ALL the products you use in your skincare regimen? Example: Cleanser(s), Toner(s), Serum(s), Face Mask(s), Moisturizer(s), and SPF. Please also include the product(s) that contain any active or exfoliating ingredients.

Are you currently or have you ever experienced any of the medical or cosmetic procedures before? (check all that apply)

Do you have any other medical concerns that have not been covered in this form?

If Yes, please explain:

Do have any allergies? Products used in the treatment room are botanically derived such as papaya, lavender, and so on. Please list any irritants and/or allergies below:

Celluma LED Light Therapy is a modality that is offered in my treatment room. While this treatment is very safe, it's important to note not everyone is a candidate for this modality. Listed below are contraindications to the LED modality. Select all that apply to you. Your service provider will adjust your treatment if needed.

PLEASE READ:

If you have received any Botox, Fillers, or Laser Treatments within the last 14 days, please reach out about rescheduling your service to ensure the safety of your skin and the longevity of your other treatments.

If you are experiencing an active Cold Sore now or on the day of your appointment, you will be asked to reschedule. Please wait 2-3 weeks before rescheduling. You may also acquire an antiviral prescription from your medical provider to help speed up healing.

If you have received any Recent Facial Piercings, please let me know if it is still healing so I can avoid the area and be gentle.

If you just had Facial Surgery, please wait 3 months to schedule a facial.

If you just Suntanned, went in a Tanning Bed recently, or used Fake Tanner - please wait 1 week to schedule a facial.

I have read the above paragraph and acknowledge that I have not recently experienced any cosmetics treatments or medical procedures that would impact my facial appointment with Ashlee Tomlin.

Without names, are you taking any medications where you noticed it has affected your skin? Example: redness, rash, hives, blisters, skin thinning, pain, bruising, and so on. If you are not taking any medications, please put "No Medications."

Do you take any vitamins? For example: Multi-Vitamin, Spirulina, Chlorella, B12, Biotin, Magnesium, Vitamin D, Protein Powder, and Other? If you are not taking any vitamins, please put "No Vitamins."

Do you regularly workout?

How would you like to enjoy your facial with Ashlee today?

I'm currently building my portfolio. Would it be okay to take before and after photos / videos of the treatment?

The Client Consultation Form is now complete and has been answered truthfully and to the best of the Client's knowledge. The answers given constitute a full disclosure of the Client's skin and health background at the time and date of the service. This agreement supersedes any previous verbal or written disclosures. The Client understands that withholding information or providing misinformation may lead to undesirable results, contraindications, and/ or skin complications.

The treatments received at BB Meme Hillcrest are voluntary. The client understands the risks and consents to Ashlee Tomlin providing the service. This agreement releases Ashlee Tomlin, Koji Kuninaga, and BB Meme Salon Hillcrest from any potential conditions that may arise after treatments that were not previously disclosed at the time and day of service.

Please Sign Below:

Signature

Date

Thank you so much for taking the time to fill out the consultation form.
Looking forward to seeing you!