Facial Treatment Consultation Form

1
Name* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.
Date
Year
Month
Day
3
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Phone Number* This field is required.
Please enter a valid phone number.
5
Email* This field is required.
example@example.com
6
Emergency Contact * This field is required.
First Name
Last Name
7
Phone Number* This field is required.
Please enter a valid phone number.
8
How did you hear about us?* This field is required.
Instagram
Tiktok
Referral
Other
9
If referred, by who?
10
Do you have or have you had any of the following conditions? If yes, select them* This field is required.
Acne
Arthritis
Asthma
Blood Disorder
Cancer
Diabetes
Eczema
Epilepsy
Heart Condition
High Blood Pressure
HIV/ AIDS
Hyper Pigmentation
Hypo Pigmentation
Immune Disorders
Insomnia
Lupus
Depression
Anxiety
Migraines
None
Other
11
Any other condition:
12
Any known allergies?
13
List any medications you take regularly, including vitamins, herbal supplements, aspirin:
14
Any recent surgery, including plastic surgery? If so, when?
15
Are you on birth control?
YesNo
16
Are you pregnant or trying to become pregnant?
YesNo
17
What are your skin concerns?
18
What is your skin type?* This field is required.
Normal (No visible blemishes, fine pores, smooth texture)
Sensitive (Reactive to fragrance, often irritated)
Combination (Oily and dry patches, hormonal breakouts)
Oily (Excessive oil, enlarged pores)
Dry (Dull, visible lines and wrinkles)
Acne
19
What skin care products do you use on the daily basis?* This field is required.
Make-Up Remover
Cleanser
Facial Soap
Toner
Serum
Mask
Exfoliants
Eye Cream
Moisturizer
SPF
Vitamin A (Retinol)
None
20
Have you been diagnosed with eczema, psoriasis, or rosacea?
YesNo
21
In the last 3 months have you used Retin-A, Renova, AHA’s or Retinol/Vitamin A derivative
YesNo
22
If yes, please specify which product or type.
23
Have you received Botox, Restylane, or Collagen injections in the last 6 months? If so, when?
24
Have you received chemical peels, laser services, or microdermabrasion treatments?
Yes, within the last month
Yes, within the last 2-3 months
No
Type option 4
25
By signing below, you agree to the following:

I have completed this form truthfully and to the best of my knowledge. I agree to inform the technician of any changes in the information above. I agree to waive all liabilities toward my technician and for any injury or damages incurred due to any misrepresentation of my health history.
26
Cancellation Policy* This field is required.I understand that cancellation must be done with at least a 12 hour notice. Failure to do so will result to being charged 50% of the service. I understand that after 10 minutes, a $10 fee will be applied and after 15 minutes of tardiness, my appointment will be canceled and I will be charged 50% from the service.
27
Signature* This field is required.
28
Date* This field is required.
Date
Year
Month
Day
Should be Empty: