Client Consultation Form

Client Consultation Form
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number*
Please enter a valid phone number.
Would you like to receive promotional messages from us?*

Yes, by emailYes, by text messageNo, I do not want to receive promotional messages
Sex

FemaleMaleOther
What's your preferred pronoun?
How were you referred to us?
Occupation
Does your job require that you work outdoors?

YesNo
What would you like to achieve from your treatment?
Your Skin Care
Have you ever had a facial treatment before?

YesNo
If Yes, when?
Have you ever had a body spa treatment before?

YesNo
If Yes, when?
Which of the following best describes your skin type?

Type 1 Fair skin tones - Always burns, never tansType 2 Light skin tones - Burns easily, tans slightlyType 3 Fair to olive skin tones - Burns moderately, tans moderatelyType 4 Dark brown skin tones - Rarely burns, tans easilyType 5 Dark brown to black skin tones - Never burns, tans easily
Do you have any special skin problems or concerns pertaining to your face or body?

YesNo
If Yes, please specify?
Have you ever had chemical peels, laser treatments, or microdermabrasion?

YesNo
If yes, within the last month?

YesNo
Do you use Accutane, Retin-A, Renova, Adapalene, Hydroxyl Acid or any other Retinol/vitamin A derivative products?

YesNo
If yes, please specify what and when last used:
Have you used acne medication?

YesNo
If yes, When?
Which Medication?
Have you experienced Botox, Restylane, or collagen injections?

YesNo
If yes, please specify?
What skin care products are you currently using? (List brands if known)
Have you used any hair removal methods in the past six weeks?

YesNo
If yes, check all that apply

ShavingWaxingElectrolysisPluckingTweezingStringingDepilatoriesOther
If other, please specify.
Do you experience ingrown hairs as a result of hair removal?

YesNo
If yes, please specify.
What areas of concern do you have regarding your Skin? (Check all that apply)

Breakouts/AcneSun DamageRosaceaFlaky SkinSun/Liver/Brown SpotsUneven Skin ToneExcessive oil/shineDull/Dry SkinRedness/RuddinessBlackheads/WhiteheadsWrinkles/Fine LinesBroken CapillariesDehydratedOther
If other, please specify.
What areas of concern do you have regarding your Eyes? (Check all that apply)

DehydratedDark CirclesWrinklesPuffinessOther
If other, please specify.
What areas of concern do you have regarding your Lip? (Check all that apply)

DehydratedCracked/Chapped LipsOther
If other, please specify.
Have you ever had an allergic reaction to any of the following? (Check all that apply)

CosmeticsFragranceAnimalsDrugsAHAsFoodLatexIodineMedicationShellfishSunscreensPollenOther
If yes/other, please specify
What SPF do you use on your face?
How often/when?
Have you recently used any self-tanning lotions, creams, or treatments?

YesNo
If yes, please specify.
Have you had any recent tanning bed or sun exposure that changed the color of your skin?

YesNo
If yes, please specify.
Health History
Are you taking any oral contraceptives?

YesNo
If yes, please specify.
Have you experienced any recent changes to or from your contraceptives?

YesNo
If yes, please specify.
Are you pregnant or trying to become pregnant?

YesNo
Are you experiencing any menopausal symptoms?

YesNo
If yes, please specify.
Are you currently undergoing any hormone therapy treatments?

YesNo
If yes, please specify.
Are you under any medications?
Do you have any allergies?
Do you have any past medical history?
Lifestyle
How many glasses of water do you drink per day?

<1 glass1-3 glasses4-7 glasses8+ glasses
How many caffeinated beverages (coffee, tea, soda, etc) do you consume per day?

None1-2 drinks3-5 drinks6+ drinks
How many alcoholic beverages do you consume per week?

I don't drink1-3 drinks4-7 drinks8+ drinks
How many hours of sleep do you get per night?

<3 hours3-5 hours6-8 hours8-10 hours10+ hours
Which foods do you consume on a regular basis?

FruitsFishVegetablesGrains/BreadDairy/EggsProcessed SugarCheeseProcessed MeatsPoultry
What does your daily commute look like?

CarBikePublic TransportationWalkI don't commute
How often do you travel on a plane?

Never1-2 times per year1-2 times per quarterEvery monthEvery week
How many hours do you spend in front of a screen or digital device?

<3 hours4-6 hours7-9 hours10-12 hours12+ hours
Do you exercise on a regular basis?

YesNo
Do you smoke cigarettes, vape, or consume other tobacco products?

YesNo
Type a question
What are your stress levels on a scale from 1 to 5 (1 = low stress, 5 - high stress)?
General Consent

Although every precaution will be taken to ensure your safety and well-being before, during, and after your treatment/procedure, please be aware of the following information and possible risks and indicate that you fully understand what to expect.
I hereby consent to and authorize the technician/esthetician to perform the following treatment/procedure:
Treatment / Procedure
Initial
I voluntarily agree to undergo this treatment/procedure after the nature and purpose of this treatment/procedure has been explained to me, along with the risks and hazards involved.
Initial
Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications.
Initial
I understand that it is imperative to my health and safety that I disclose all of the information requested in the Client Consultation/Health History form. I have cited all conditions and circumstances regarding my health history, allergies, and medications, supplements, or prescriptions being taken (orally and/or topically), and any past reactions to products or medications.
Initial
I understand that no specific guarantees of the results can or have been made and that there is the possibility I may require additional treatments/procedures to obtain the expected results at an additional cost.
Initial
I have read and understand all pre-treatment, post-treatment, and home care instructions. I understand the importance of following all instructions given to me. In the event that I have additional questions or concerns regarding my treatment or post-treatment care, I will consult the technician/esthetician immediately. I understand that if I choose to consult a physician, I do so at my own expense.
Initial
I consent to “before-and-after” photographs for the purpose of documentation, potential advertising, and promotional purposes.
Initial
I understand that if I have any concerns, I will address these with my technician/esthetician. I give permission to my technician/esthetician to perform the above treatment/procedure we have discussed and will hold him/her/them and
his/her/their staff harmless and nameless from any liability that may result from this treatment/procedure. I understand my technician/esthetician will take every precaution to minimize or eliminate negative reactions as much as possible. I
agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read and fully understand the above paragraphs and that I have been provided sufficient opportunity for
discussion and to have any questions answered. I understand the procedure and accept the risks. I do not hold the technician/esthetician, whose signature appears below, responsible for any of my conditions that were present but not
disclosed at the time of this procedure that may be affected by the treatment performed today.
For Client
For Technician / Esthetician ONLY
Future Appointments/Contact
May I call you at the provided phone number to confirm future appointments?

YesNo
May I contact you via mail/email about future promotions and news?

YesNo
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 institution and/or the technician/esthetician/skin care professional from liability and assume full responsibility thereof.
Should be Empty:

Client Consultation Form

Your Skin Care

Health History

Lifestyle

General Consent

Future Appointments/Contact