Skincare Consultation Form
Date
*
-
Month
-
Day
Year
Date Picker Icon
Name
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Format: (000) 000-0000.
E-mail
*
example@example.com
How did you hear about us?
Website / Online Search
Yelp
Facebook
Referral
Other
Your Skin
What are your skincare goals?
*
What are your skincare challenges?
Wrinkles / Fine Lines
Hyperpigmentation / Sun Damage
Acne / Acne Scarring
Redness / Rosacea
Sensitivity
None
Other
Have you ever had a facial or skin treatment before?
*
Yes
No
What skincare products do you currently use?
*
Cleanser / Face Wash
Bar Soap
Face Scrub / Exfoliator
Toner
Serum
Moisturizer
Sunscreen
Eye / Lip
None
Other
Do you use Retin-A, Renova, Adapalene, Accutane, Differin, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivatives?
Yes, currently using
Yes, but not within the last 30 days
Yes, but not within the last 6 months
No
Not sure
Have you received any of these hair removal services in the last 30 days?
Waxing
Sugaring
Threading
Electrolysis / Laser
No
Have you ever received chemical peels, laser services, or microdermabrasion treatments?
Yes, within the last month
Yes, within the last 2-3 months
No
Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks?
Yes
No
Your Health
Have you ever experienced claustrophobia?
Yes
No
Please rate your stress level
Low
Medium
High
Have you experienced any of these health conditions in the past or present?
*
Hormone Imbalance
Cancer / Systemic Disease
High Blood Pressure
Diabetes
Heart problem
Arthritis
Auto-Immune Disorders
Asthma
Epilepsy / Seizure Disorder
Fever Blisters
Herpes
Frequent Cold Sores
HIV/AIDS
Lupus
Depression/Anxiety
Hepatitis
Headaches / Migraines
None
Other
Do you?
*
Wear contact lenses
Have body piercings
No
Any known allergies?
*
Aspirin
Tree Nuts
Latex
Dairy
Fruits
Vegetables
Shellfish
Iodine
Fragrances / Essential Oils
None
Other
Have you used or been prescribed any medication for acne?
*
Yes
No
If yes, please specify what and date last used
Female Clients
Are you taking birth control?
Yes
No
Are you pregnant or trying to become pregnant?
Yes
No
recently had a baby
Male Clients
What is your current shaving system?
Razor
Electric
n/a
Do you experience irritation from shaving?
Yes
No
n/a
Signature
*
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