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.
18-2526-3536-4546-5656-6666+
Walk-inInstagramGoogleYelpA friend or family memberFarmer's MarketBB Meme WebsiteOther
I AgreeI Disagree
YesNo
Never BeenLast WeekLast Month2-3 Months AgoAt Least 6 Months Ago
Dry: Less Oil, Flaky, Rough Patches, Visible Lines, Less Elasticity.Normal: Balanced Skin, Even Tone + Texture, Good Elasticity, Minimal Breakouts.Combination: Mix of Dry and Oily, Prone to Acne, Tend to have Thicker Skin.Oily: Produces Extra Oil, Visible Pores, Prone to Acne.I'm not sure what my skin type is.
What are your current TOP 3 skin concerns and what improvements would you like to see? *
I'm on a regimen you recommended and I'm enjoying it.I have a regimen that works for me.I have a regimen but have yet to notice any significant improvements yet.I don't think my current regimen works for me and am open to hearing suggestions.I would like help building a complete regimen.
YesNo
I agree.I disagree, my treatment may need to be adjusted or rescheduled.
YesNo
YesNo, I've been off my acne medication for at least 6+ months.I don't take acne medication.
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. *
Heart ConditionEpilepsyDiabetesFrequent or Severe HeadachesMetal Implants / PacemakersLow or High Blood PressureTaking Birth Control / Depo ShotHRT (Hormone Treatment)Eczema / PsoriasisCold SoresFacial SurgeryLasersBotox / FillersFacial Waxing / ElectrolysisRecent Facial PiercingsTanning / Tanning BedsNo Medical or Cosmetic Procedures
YesNo
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:*
PregnancyEpilepsy / Seizure DisordersYou're under the age of 12.You have had a recent Skin Cancer lesionCurrently taking photo-sensitive medications like lithium, melatonin, phenothiazine, antipsychotics, amiodarone, digoxin, or you're on antibiotics.Steroidal Medications / This treatment should not be performed on those who have had steroid injections within the last 72 hours.I am not experiencing any of the listed contraindications.
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 agree.I disagree and will need to reschedule.
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."*
Yes, at the gym.Yes, at home.Yes, outdoors.No
I would appreciate a quiet atmosphere.I would like a quiet atmosphere with brief explanations of facial steps.I would like to chit chat.No preference.
Yes.Yes, but please block out my identity.
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*

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