New Client Consultation Form

Skincare Consultation Form
Date*

MonthDayYear
Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
E-mail*
example@example.com
How did you hear about us?

Website / Online SearchYelpFacebookReferralOther
Your Skin
What are your skincare goals? *
What are your skincare challenges?

Wrinkles / Fine LinesHyperpigmentation / Sun DamageAcne / Acne ScarringRedness / RosaceaSensitivityNoneOther
Have you ever had a facial or skin treatment before?*

YesNo
What skincare products do you currently use?*

Cleanser / Face WashBar SoapFace Scrub / ExfoliatorTonerSerumMoisturizerSunscreenEye / LipNoneOther
Do you use Retin-A, Renova, Adapalene, Accutane, Differin, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivatives?

Yes, currently usingYes, but not within the last 30 daysYes, but not within the last 6 monthsNoNot sure
Have you received any of these hair removal services in the last 30 days?

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

Yes, within the last monthYes, within the last 2-3 monthsNo
Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks?

YesNo
Your Health
Have you ever experienced claustrophobia?

YesNo
Please rate your stress level

LowMediumHigh
Have you experienced any of these health conditions in the past or present?*

Hormone ImbalanceCancer / Systemic DiseaseHigh Blood PressureDiabetesHeart problemArthritisAuto-Immune DisordersAsthmaEpilepsy / Seizure DisorderFever BlistersHerpesFrequent Cold SoresHIV/AIDSLupusDepression/AnxietyHepatitisHeadaches / MigrainesNoneOther
Do you?*

Wear contact lensesHave body piercingsNo
Any known allergies?*

AspirinTree NutsLatexDairyFruitsVegetablesShellfishIodineFragrances / Essential OilsNoneOther
Have you used or been prescribed any medication for acne?*

YesNo
If yes, please specify what and date last used
Female Clients
Are you taking birth control?

YesNo
Are you pregnant or trying to become pregnant?

YesNorecently had a baby
Male Clients
What is your current shaving system?

RazorElectricn/a
Do you experience irritation from shaving?

YesNon/a
Signature*

Clear
Should be Empty:

Skincare Consultation Form

Your Skin

Your Health