NEW CLIENT QUESTIONNAIRE

NEW CLIENT QUESTIONNAIRE

FACE REALITY ACNE TREATMENT PROGRAM
YOUR INFORMATION
Full Name*

First NameLast Name
Date Of Birth*

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

Please indicate if you have used any of the following medications in the past 2 years, when they were used and for how long:

	When	How Long
Antibiotics (oral)
Antibiotics (topical)
Accutane
Benzoyl Peroxide
Retin-A, Tazorac, Differin
Thyroid medication
Blood Thinning medication

Any additional medications not listed above:*
MEDICAL HISTORY - PLEASE CHECK ALL THE APPLY*

Herpes SimplexEczemaPsoriasisHepatitisCancerStaph Infection/MRSAHIV/AIDSThyroid ProblemsHormone ProblemsHysterectomyOvary(ies) RemovedPacemakerHemophiliaLupusAnemiaHigh Blood PressureDiabetesMetal Pins in BodyNONE OF THE ABOVE
YOUR PRIMARY CARE PHYSICIAN*

First NameLast Name
Phone Number*
Please enter a valid phone number.
YOUR DEMATOLOGIST*

First NameLast Name
Phone Number*
Please enter a valid phone number.
LIFESTYLE CONSIDERATIONS
Have you ever had any reaction to any skincare products or anything you have applied on your face?*
If yes, please explain:
Do you have any allergies including skincare ingredients, food and medications?*
Do you smoke/vape? if yes, what do you smoke?*
Do you use fabric softener or dryer sheets? *
Do you swim in a chlorinated pool? *
Do you work around chemicals, tars, oils, grease or inks? If yes, please specify:*
What is your occupation?*
Do you work nights?*
Are you currently under a lot of stress?*
Are you currently pregnant or nursing?*
Do you use birth control pills, shots, or IUD? If yes, which do you use or what brand of pill?*
Do you have shaving irritation on your face?*
What type of razor do you use for shaving (i.e. double blade, triple blade, rotary)?*
DIET

Do you consume the following?*

	How many times per week?
Fast Food
Processed Food
Salty Snacks
Milk/Yoghurt
Cheese
Whey or Soy Protein
Peanut Butter
Peanuts
Sushi
Kelp and Seaweed
Miso Soup
Soy
Vitamins/Supplements
Seafood

Have you ever used Face Reality Products? if yes, please list the products:*
Are you still using Face Reality products?*

YesNo

Products you are currently using:*

	Name of products and how often you use them:
Cleanser
Toner
Serums
Moisturizers
Sunscreen
Mask
Foundation
Blush
Exfoliant (acids, enzymes, scrubs)
Acne Medications
Others

Have you had any of the following treatments done in the last 90 days?*

Chemical PeelsMicrodermabrasionDermabrasionLaser Hair RemovalLaser Skin TreatmentSkin Cancer RemovalFacial WaxingElectrolysisOtherNone
If you have had any of the above treatment done in the past 90 days, please give more information:
ACNE TREATMENT CONSENT FORM
An acne treatment may consist of surface cleansing, mild chemical peels or steam and exfoliation, an application of antibacterial serums, corrective serums and extractions. Treatments take appoximately 30-45 minutes to complete and are designed to balance, hydrate, extract acne impactions, and prepare the skin for the home care routine.

PLEASE READ CAREFULLY BEFORE SIGNING

I have not been exposed to excessive sun and my skin does not feel sensitive or irritated in any way.

I have not had any other chemical peel of any kind, within the last 14 days of this treatment.

I have not had any facial waxing, within the last 7 days of this treatment.

I have informed the esthetician of all health problems of which I am aware including herpes simplex/cold sores.

I have informed the esthetician of any use of oral or topical medications I may be using including any retinoids (Retin-A, Renova, Avita, Differin, Tazorac) or Accutane (Isotretinoin).

I understand that clear of the skin of acne is best achived through a series of treatments and consistency with the home care product routine recommended by my Acne Expert.

I understand that I will probably not experience much visible peeling, flaking, discoloration irritation followin this procedure if I follow my home care instructions carefully.

I consent to photographs taken of my face/back to be used for monitoring treatment progress.

AFTER CARE

Avoid direct sunlight or tanning booth for at least 3 days following a treatment.

Use of sunblock protection is necessary following all treatment.

Do not pick your skin following a treatment.

Face Reality Skincare products are clinical-strength active formulas. Mild tingling sensations are possible with product application but should not be irritating. If you are experiencing stinging and/or irritation with any product, stop using the product and contact your Acne Expert for guidiance.

I hereby agree to all of the above and agree to have this treatment performed on my skin. I further agree to follow all post-treatment care instructions as I am directed.
Cancellations and Late Arrival Policy
If you must cancel or reschedule your appointment, we respectfully request at least 24 hour notice. Cancellations without 24-hour notice or no-shows will result in a 50% charge of the full service amount either to your credit card or it will be included at your next appointment.

If you are late for your appointment, we will try our best to accommodate. However, please keep in mind that your service time may be cut in order for us to be on time for the next client after you. You will still be responsible for the full amount of all services booked.
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Date*

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NEW CLIENT QUESTIONNAIRE

LIFESTYLE CONSIDERATIONS

DIET

ACNE TREATMENT CONSENT FORM

Cancellations and Late Arrival Policy