Core Skin Studio Consultation Form

Core Skin Studio Consultation Form

While this consultation form is a little lengthly (apologies in advanced) - it is required to make sure we can review and address all concerns, medications, current skincare/lifestyle, allergies, and or any other contraindications prior to your appointment.
Basic Information
Legal Name

First NameLast Name
Preferred Name (if different than above)

First NameLast Name
Birthday

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email (no icky spam emails, I promise!)
example@example.com
How did you hear about us
Name of referral (to track referral bonus!)
Occupation
Ethnicity (multiple selection, if applicable)

Other
Skin History + Concerns
What are your current skin concerns? (check all that apply)

Other
How long have you had these concerns?
What are your main skin goals?
Have you had a reaction to a skincare product or treatment before?
If you answered yes to the previous question, please explain.
Have you had a facial or skin treatment before?
When was your last treatment?
What was the name of the treatment?
Have you had a chemical peel or laser treatment in the last 2 years?
Have you had plastic surgery, filler, botox, POD threads, or any other cosmetic procedures?
If yes, please give short description as to each procedure you've had above and when and/or how long you been receiving.
Name or brand of peel(s)?
Current Skincare Routine
Please list current skincare you use at home (AM/PM/weekly)


Please list all current skincare you use at home (AM/PM/Weekly/Monthly)
Are you currently using an prescription skincare? (tretinoin, hydroquinone, topical antibiotics, topical steroid creams)
If you answered yes to the question above, please explain
Are you consistent with your routine?
Does your current routine deliver the results you desire?
Do you exfoliate? (Physically or chemically) examples: scrubs, aha, bha, retinols, benzoyl peroxide
If yes, what type of exfoliant do you use?
How often do you exfoliate
Do you use sunscreen daily?
Are you currently using any Retinol, AHA, BHA or any peeling agent?

Other
If yes, what products?
How long have you been using this/these product(s)?
If yes, please describe.
Internal Health Snapshot + Lifestyle

(This section helps identify possible factors influencing your skin)
Which of the following best describes your typical eating style?

Other
Which of the following best describes your typical eating style?
Do you have any food allergies outside of gluten or dairy?
Please list any vitamins, dietary or herbal supplements you take/consume daily (non-prescription) If you do not take any, please list N/A.
Please list any vitamins and dietary or herbal supplements you consume. (non-prescription)
Do you smoke? (cigarettes, vapes, cannabis)
Do you drink alcohol? (can be mixed drinks, wine, or canned drinks such as beer, seltzers, etc.)
Does your diet consist of many added sugars? (Over 50g daily)
Do you consume any type of supplementary protein such as protein bars, drinks, or powders? If yes, please explain.
How much water do you consume per day? (in ounces or cups)
How much coffee/tea/energy drinks (caffeine) do you consume per day? (in ounces or cups)
Rate your stress level (0-10; 0=no stress, 10=chronic stress)
How often do you exercise or move your body?
How many hours of sleep do you get a night? (on average)
How often do you have a bowel movement? (helps with gut-skin connection)
Medical Diagnoses + Health Conditions

Please make sure you list any and all past/present diagnoses
Digestive & Gut Health: check all that apply

Other
Metabolic & Autoimmune: check all that apply

Other
Hormonal + Reproductive Health: check all that apply

Other
Are you currently on any form of birth control?
Are you or could you be pregnant and/or nursing?
Are you currently trying to get pregnant or undergoing infertility treatment?
Have you ever had your hormones tested?
Cardiovascular, Blood & Oncology History: check all that apply

Other
Skin-Related Conditions: check all that apply

Other
Do you have a tendency to keloid scar?
Mental Health & Nervous System: check all that apply

Other
Have you in the past or present had any of the following?

Other
Do you suffer from claustrophobia?
Have you been under a physicians care during the past 3 years? (Other than physical/routine check ups)
If yes, please describe.
Allergies

Please list any known or suspected allergies or sensitivities — topical, environmental, or internal (including foods, medications, skincare, etc.).
Common allergies to check if applicable:

Other
If needed, please explain allergies in more detail
Do you have a history of anaphylaxis? (severe allergic reaction)

Other
If you selected "Other" above, please list any other medical conditions or history
Medications

Please list all medications you are currently taking (prescription or over-the-counter, including any hormonal therapy)
Are you currently taking any medications?
Medication List (if you answered yes above, please list all current medications)
Are you currently taking accutane or roaccutane?
Have you taken accutane or roaccutane in the past?
If yes, how many rounds and when?
Name of prescription medications and how long you've been on them (Put N/A if not applicable)
If yes, what form are you currently using? For how long?
Consents + Signature
Medical Disclaimer & Service Eligibility: I understand that Mikayla (Core Skin Studio) is not a medical professional. Core Skin Studio has the right to deny service or ask for written approval from a doctor if there is a significant risk involved due to health complications, pregnancy, allergies, conditions, etc.
Treatment Sensation & Reaction Acknowledgment: Treatments provided by Core Skin Studio are results-focused and may cause temporary sensations such as tingling, itching, or warmth, as well as slight erythema (redness). I understand that these reactions are normal and typically subside within 20-35 minutes after my appointment. I recognize that individual responses may vary and that any prolonged or unusual reactions should be reported to Core Skin Studio as soon as possible.
Treatment Photo Policy: At Core Skin Studio, we document each treatment with photos to monitor progress and maintain accurate client records. These photos are taken before and/or after each session and are required for legal, clinical, and goal-tracking purposes.
Optional Social Media / Marketing Consent: Occasionally I share real client results on my website and social media to showcase the effectiveness of treatments and educate others on skin health. Your privacy is a top priority and I will never tag you or share your name. Photos may include full face, partial face, or close-up skin areas (cheek, jawline, forehead).
I agree to not bring any guests (including children) without prior approval from Core Skin Studio
Client Responsibility & Disclosure Agreement: I have, to the best of my knowledge and ability, disclosed all known allergies, medications, medical conditions, and diagnoses at the time of filling out this form. I understand that withholding or failing to disclose relevant information may increase the risk of adverse reactions. Core Skin Studio is not liable for any complications, reactions, or issues arising from undisclosed or inaccurate information and is released from any legal responsibility in such cases.
Client Typed Signature (Full Legal Name)
THANK YOU!!
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Core Skin Studio Consultation Form

Basic Information

Skin History + Concerns

Current Skincare Routine

Internal Health Snapshot + Lifestyle

Medical Diagnoses + Health Conditions

Allergies

Medications

Consents + Signature

THANK YOU!!