New Client Consultation Form

Name

First NameLast Name

Date of Birth

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

E-mail

How did you hear about me?

If Referral, please list name

If Other, please let me know

What are your skin care goals?

What are your skin care challenges?

Have you ever had a facial or skin treatment before?

If Yes, when?

What Skin Care Products do you currently use?

If you are seeking corrective treatments please detail the SPECIFIC products (BRAND & PRODUCT TYPE/NAME) you are currently using so I can best answer any questions on ingredients and help you meet your skin care goals.

Cleanser / Face Wash

Bar Soap

Face Scrub / Exfoliants

Toner

Serums

Moisturizer(s)

Sunscreen

Eye Product(s)

Lip Product(s)

Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?

Please specify which product or type, if you answered 'Yes, currently using' to above.

Have you received any of these hair removal services in the last 30 days?

If checked, please note last time.

Have you ever received chemical peels, laser services, or microdermabrasion treatments?

Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks?

If you checked yes to any of these please provide further information. If not mark N/A

Do you?

Do you take any of the following dietary / health supplements?

If other, please list

Any known allergies?

If Other, please specify

Have you used or been prescribed any medications (topical or oral) for acne / acne control?

If yes, please specify what and date last used

Please rate your stress level

Please let me know if you would like to learn about natural ways to lower stress levels

Are you pregnant or trying to become pregnant?

Are you undergoing any hormone replacement therapy?

If yes, please specify

Do you experience irritation from shaving?

Post Facial Care/Waxing Instructions: Aerobic exercise and/or vigorous physical activity should be avoided for 48 hours. Direct sunlight exposure is to be avoided immediately following the treatment (including any strong UV light exposure and/or tanning beds). If some sun exposure cannot be avoided first apply a broad spectrum sunscreen of SPF 30. Sunscreen (with a minimum SPF 15) should become part of your daily skin care regimen as skin can potentially become more sensitize to the sun as a result of this treatment. Unless otherwise specified, in the evening following your treatment, cleanse your skin with a mild cleanser and water followed by a non-active moisturizer. Do not apply additional exfoliating ingredients/products the day of your service as over-exfoliation can result in irritation or further sensitivity. Consult your skin care professional before resuming topical treatments. Enzyme peels, Gua Sha, Facial cupping, Nano needling, chemical peels or facial waxing can result in skin flushing/redness or slight skin flaking or sensitivity for up to 48-72 hours post treatment. DO NOT peel, pick, rub, or scratch your skin at any time, whatsoever. This can potentially cause damage or compromise your results.

Reservation & Cancellation Policy for all current and future appointments: a valid credit card is required for all appointments. Please do not forget to confirm your appointment when you receive your reminder. In the event of cancellations received less than 24 hours prior to appointment, a cancellation fee equal to the reserved service booking will incur; No Shows will be charged a $15 fee

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 skin care professional from liability and assume full responsibility thereof.

Signature

New Client Consultation Form

Your Skin