Client Consultation Form

Client Consultation Form
NAME*
DATE of BIRTH*

MonthDayYear
Date
Address
PHONE
Format: (000) 000-0000.
Sex:

MaleFemaleNonbinary
EMAIL
example@example.com
How were you referred to us?*
What would you like to achieve from your treatment today?
Occupation
Does your job require that you work outdoors?

NoYes
If yes, please specify when and what treatment
Have you ever had a facial treatment before?
Which of the following best describes your skin type? (Please check one)

Type I Fair skin tones-Always burns, never tansType II Light skin tones-Burns easily, tans slightlyType III Fair to olive skin tones-Burns moderately, tans moderatelyType IV Light brown skin tones-Burns slightly tans easilyType V Dark brown skin tones-Rrely burns, tans easilyType VI Dark brown to black skin tnes-Never burns, tans easily
Do you have any special skin problems or concerns pertaining to your face or body?

NoYes
If yes, please specify:
Do you use Accutane, Retin-A, Renova, Adapalene Hydroxyl Acid or any other Retinol/vitamin A derivative products?

NoYes
If yes, please specify what and when last used
Have you used acne medication? Which medication? When?
What skin products are you currently using?

(List brands, if known)
Cleanser
Toner
Day Moisturizer
Night Moisturizer
Exfoliator
Mask
Eye Product
Body Lotions
Soap
Scrubs
Eye Products
Shower Gels
Spf/Sunscreen
Have you used any hair removal methods in the past six weeks? Please check all that apply

ShavingWaxingElectrolysisPluckingTweezingDepilatoriesOther
What areas of concern do you have regarding your skin? Check all that apply

Breakouts/acneUneven skin toneSun damageExcessive oil/shineRosaceaDull/dry skin Flaky skinRedness/ruddinessDehydrated Sun/liver/brown spotsOther
Eyes (Check all that apply)

DehydratedDark circlesWrinklesPuffinessOther
Lips (Check all the apply)

Wrinkles OtherCracked/chapped lipsDehydratedOther
12 Have you ever had an allergic reaction to any of the following? Check all that apply

CosmeticsFragranceAnimalsDrugsAHAsFoodLatexIodineMedicationShellfishSunscreensPollinsIf yes, please specify:
What SPF do you use on your face?
How often/when?
Have you had any recent tanning bed or sun exposure that changed the color of your skin?

NoYes
If yes, please specify
How many glasses of water do you drink per day? Please check one

1-2 glasses3-5 glasses6+ glasses
How many caffeinated beverages do you drink per day? (coffee, teas, soda, etc)Please check one

1-2 drinks3-5 drinks6+ drinksNone
How many alcoholic beverages do you consume per week) (Please check one)

1-2 drinks3-5 drinks6+ drinks8+ drinks
What does your daily commute look like?

CarBikePublic transportWalkI don't commute
How many hours of sleep do you get per night?

Less than 3 hours3-5 hours6-8 hours8-10 hours10+ hours
How often do you travel on a plane?

Never1-2 times per year1-2 times per quarterEvery monthEvery week
How many hours do you spend on front of a screen or digital device?

Less than 3 hours4-6 hours7-9 hours10-12 hours
Do you exercise on a regular basis?

NoYes
Are you taking oral contraceptive treatments?

NoYes
If yes, please specify
26 What are your stress levels on a scale from 1 to 5 (1 = low stress, 5 = high stress)?
Are you pregnant or trying to become pregnant?

NoYes
Are you experiencing any menopausal symptoms?

NoYes
If yes, please specify what and when
Are you undergoing any hormone replacement therapy treatments

NoYes
If yes, please specify
Male Clients
Do you experience irritation from shaving?

YesNo
If yes, please specify
May I contact you via mail/email about future promotions and news?

NoYes
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 are voluntary and I release this institution and/or the technician/esthetician/skin care professional from liability and assume full responsibility thereof.
Client Name (Printed)*
Client Name (Signature)*
Date*

MonthDayYear
Date
Should be Empty:

Client Consultation Form

What skin products are you currently using?

Male Clients