Client Consultation Form

  • Client Consultation Form

  • Format: (000) 000-0000.
  • Would you like to receive promotional messages from us?*
  • Sex
  • Does your job require that you work outdoors?

  • Your Skin Care

  • Have you ever had a facial treatment before?
  • Have you ever had a body spa treatment before?
  • Which of the following best describes your skin type?
  • Do you have any special skin problems or concerns pertaining to your face or body?
  • Have you ever had chemical peels, laser treatments, or microdermabrasion?
  • If yes, within the last month?
  • Do you use Accutane, Retin-A, Renova, Adapalene, Hydroxyl Acid or any other Retinol/vitamin A derivative products?
  • Have you used acne medication?
  • Have you experienced Botox, Restylane, or collagen injections?
  • Have you used any hair removal methods in the past six weeks?
  • If yes, check all that apply
  • Do you experience ingrown hairs as a result of hair removal?
  • What areas of concern do you have regarding your Skin? (Check all that apply)
  • What areas of concern do you have regarding your Eyes? (Check all that apply)
  • What areas of concern do you have regarding your Lip? (Check all that apply)
  • Have you ever had an allergic reaction to any of the following? (Check all that apply)
  • Have you recently used any self-tanning lotions, creams, or treatments?
  • Have you had any recent tanning bed or sun exposure that changed the color of your skin?

  • Health History

  • Are you taking any oral contraceptives?
  • Have you experienced any recent changes to or from your contraceptives?
  • Are you pregnant or trying to become pregnant?
  • Are you experiencing any menopausal symptoms?
  • Are you currently undergoing any hormone therapy treatments?

  • Lifestyle

  • How many glasses of water do you drink per day?
  • How many caffeinated beverages (coffee, tea, soda, etc) do you consume per day?
  • How many alcoholic beverages do you consume per week?
  • How many hours of sleep do you get per night?
  • Which foods do you consume on a regular basis?
  • What does your daily commute look like?
  • How often do you travel on a plane?
  • How many hours do you spend in front of a screen or digital device?
  • Do you exercise on a regular basis?
  • Do you smoke cigarettes, vape, or consume other tobacco products?

  • 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 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.

  • Future Appointments/Contact

  • May I call you at the provided phone number to confirm future appointments?
  • May I contact you via mail/email about future promotions and news?

  • 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.

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