Healing Skin Ritual
New Client Consultation and Consent Form
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Birthday
-
Month
-
Day
Year
Date
Occupation
Emergency Contact/ Phone number
How did you hear about Sage & Soul Esthetics?
Would you like to receive texts regarding promotions and updates?
Yes
No
Do you have any of the following Health Conditions? Please check all that apply.
Arthritis
Asthma
Auto-Immune Disorder
Cancer
Claustrophobia
Diabetes
Digestive Disorders
Epilepsy
Heart Disease
HIV/ AIDS
High / Low Blood Pressure
Hormone Imbalance ( PCOS/Thyroid/Other)
Liver/ Kidney Disease
Pregnant or trying
Pacemaker/ Metal rods/ plates
Other
Do you have or ever experienced any of the following?
Anxiety
Depression
Panic Attacks
Trauma/ PTSD
Insomnia
Other
Do you take any medication? If so, please list them below.
Any other relevant health information?
Do you have any of the following Skin Conditions?
Acne
Eczema
Rosacea
Dermatitis
Psoriasis
Sensitive/ Reactive skin
What would you consider your skin type?
Dry
Normal
Oily
Combination
Tell me a little bit about your skin journey!
What do you LOVE about your skin?
What are your skin GOALS?
What are your skin concerns?
What external factors trigger your skin concerns?
What skin products are you currently using?
Have you ever been on ACNE medication? If so, please specify below.
Are you currently using any prescribed topical treatments? If so, please specify below.
Have you had any Botox/ Injections/ Laser/ Microderm/ Chemical peels in the last month?
Yes
No
Other
Do you have any allergies or sensitivities?
Have you had any hair removal in the past 7 days? (waxing/threading/shaving)
What is your Stress Level?
Low
Medium
High
Other
What are your expectations for your service?
Are you comfortable with me using crystals/ Gua Sha/ and other modalities during your service?
Yes
No
Maybe
Other
Are you comfortable with being photographed for potential social media content?
Yes
No
Maybe
Are you comfortable with a scalp/ hand/ arm/ and shoulder massage?
Yes
No
Maybe
Are you comfortable with me recommending products/ services to help you meet your desired skin goals?
Yes
No
Sage & Soul Esthetics is a safe space for you to unwind & allow your mind, body, and soul to relax. For me to provide the best service possible please choose one of the options below.
I prefer no talking during my service so I can fully relax.
Talking during my service helps me feel more comfortable and relaxed.
Client Consent
By signing below, you agree that you answered the information above truthfully and to the best of your knowledge and will inform me if anything changes.
Signature
Date
-
Month
-
Day
Year
Date
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