New Client Consultation Form

  • SKIN ASSESSMENT FORM

  • Date*
     - -
  •  -
  • How did you hear about us?*

  • Let’s Get Skin Deep

  • What are your skin care challenges?*

  • Have you ever had a facial or skin treatment before?*
  • What Skin Care Products do you currently use?*

  • Please detail the SPECIFIC products (BRAND & PRODUCT TYPE/NAME) you are currently using so we can best answer any questions on ingredients and help you meet your skin goals. 

  • Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?*
  • Have you ever received chemical peels, laser services, or microdermabrasion treatments? *
  • Have you received any of these services in the last 30 days?*

  • Your Health

  • Have you experienced any of these health conditions in the past or present?*
  • Do you?*
  • Do you take any of the following dietary / health supplements?

  • Any known allergies?*

  • Have you used or been prescribed any medications (topical or oral) for acne / acne control?*
  • Are you a smoker? *
  • Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)*
  • Have you ever experienced claustrophobia? *
  • Please rate your stress level*

  • FEMALE CLIENTS

  • Are you taking birth control? *
  • Are you pregnant or trying to become pregnant?*
  • Any menopause issues? *
  • Are you undergoing any hormone replacement therapy?

  •          Post Treatment Care Instructions:

    • Aerobic exercise and/or vigorous physical activity should be avoided for 48 hours.
    • Direct sunlight exposure is to be avoided immediately following the treatment (including any strong UV light exposure and/or tanning beds).
    • If some sun exposure cannot be avoided first apply a broad spectrum sunscreen of SPF 30. Sunscreen (with a minimum SPF 15) should become part of your daily skin care regimen as skin can potentially become more sensitize to the sun as a result of this treatment.
    • Unless otherwise specified, cleanse your skin in the morning with a gentle cleanser and water followed by a non-active moisturizer.
    • Do not apply additional exfoliating ingredients/products for a week after and prior to your service. As over-exfoliation can result in irritation or further sensitivity.
    • Consult your skin therapist before resuming topical treatments.
    • Chemical peels or facial waxing can result in skin flushing/redness or slight skin flaking or sensitivity for up to 48-72 hours post treatment.
    • DO NOT peel, pick, rub, or scratch your skin at any time, whatsoever. This can potentially cause damage or compromise your results.
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