New Client Consultation Form

Client Consultation Form
While this consultation form may appear long and in depth, all questions are essential and need to be answered as many may impact the specific treatment under consideration.

Some contraindications and indications may give concern to treatments, yet treatment and treatment plans may be modified.

Treatments are undertaken based on the information you provide and the practitioner reserves the right to refuse proposed treatment based on information disclosed within this form if they feel it is unsafe or will not yield the desired results.

Please ensure all questions answered are accurate and any questions needing further explanation are brought to the practitioners attention.
Date*

MonthDayYear
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*
E-mail*
example@example.com
How did you hear about me?

Website / Online SearchInstagramFacebookReferralOther
If Referred, please list name
If Other, please detail
Your Skin
What is your main reason for visiting and your skin care goals?
What are your skin concerns?

Wrinkles / Fine LinesHyperpigmentation / Sun DamageAcne / Acne ScarringRedness / RosaceaDullnessAgingMelasmaSensitivitySkin TextureDrynessOther
Please feel free to go into more detail
Have you ever had a facial or skin treatment before?*

YesNo
If yes, when and what treatments?
What Skin Care Products do you currently use?*

Cleanser / Face WashTonerSerumsMoisturiserPhysical ExfoliantsChemical ExfoliantsSunscreenTissue/Sheet MasksHome LED/other home devices
If you are seeking corrective treatments please detail the SPECIFIC products (BRAND & PRODUCT TYPE/NAME) you are currently using so I can best answer any questions on ingredients and help you meet your skin care goals.
Cleanser / Face Wash
Toner
Serums
Moisturiser(s)
Physical Exfoliants
Chemical Exfoliants
Sunscreen
Tissue/Sheet Masks
Home LED/other home devices
Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?*

Yes, currently usingYes, but not within the last 30 daysYes, but not within the last 6 monthsNoNot sure
Please specify which product or type, if you answered 'Yes, currently using' to any of the above.
Have you received any of these hair removal services in the last 30 days?*

WaxingSugaringThreadingElectrolysis / LaserDepliatory CreamShavingNone
Have you ever received chemical peels, laser services, or microdermabrasion treatments?*

Yes, within the last monthYes, within the last 2-6 monthsNo
If yes, how did you react?
Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks?*

YesNo
Have you ever had an irritant/allergic reaction to skin products?*

YesNo
If yes, please describe
Do you have cosmetic tattoos or permanent makeup in the treatment area?*

YesNo
Do you use tanning products or solariums on the treatment area?*

YesNo
Your Health
Do you?*

Wear contact lensesHave a pacemakerHave metal implantsHave body piercings (in the treatment area)None of the above
Do you take any of the following dietary /health supplements?*

MultivitaminVitamin CVitamin D/D3ZincOmega 3 / Fish OilB Complex / B12GarlicCalciumFolic AcidMelatoninCoenzyme Q10BiotinOtherNone
Do you have, or have you had any of the following?*

Hormone ImbalanceCancer / MelanomaHigh Blood PressureEczemaEasily BruisedAuto-Immune DisordersAsthmaEpilepsy / Seizure DisorderPacemakerHerpesFrequent Cold SoresHIV/AIDSLupusHeart ConditionsHepatitisHeadaches / MigrainesThyroid ConditionsBlood ClotsKeloid ScarringActive InflammationPsoriasisLack of sensation in treatment areaActive InfectionsNoneOther
If other, please list
Do you have any known allergies?*

AspirinTree NutsLatexDairyFruitsVegetablesShellfishIodineFragrances / Essential OilsOtherNone
If Other, please specify
Do you have a personal history of Diabetes?*

YesNo
If yes, what type and indicate any Insulin or Oral medications being used
Have you used or been prescribed any medications (topical or oral) for acne/acne control such as Roaccutane?*

YesNo
If yes, please specify when last taken and for how long?
Are you aware of any medication taken that is photosensitising? (medications that cause an increase in UV sensitivity)*

YesNo
Are you a smoker?*

YesNoSocial
Do you drink more than 3 caffeinated beverages per day? (tea, coffee, soda, energy drinks)*

YesNo
Have you ever experienced claustrophobia?*

YesNo
Please rate your stress level*

LowMediumHigh
How much water do you consume daily?*

Almost noneLess than a LitreMore than a Litre
How many glasses of alcohol do you consume per week?*

None1-33-55-77-10More
Do you exercise regularly?*

NeverOnce per week2 - 3 times per weekMore than 3 times per week
Determine your Fitzpatrick skin type score by using the below chart
What is your Fitzpatrick skin type score?*

IIIIIIIVVVIUnsure
FEMALE CLIENTS
Do you experience regular menstruation?

YesNo
Are you taking birth control?

YesNoN/A
If yes, what kind
Are you pregnant or trying to become pregnant?

YesNoRecently had a baby and am breastfeedingN/A
Do you experience any menopause issues?

YesNoN/A
If yes, please specify
Are you undergoing any hormone replacement therapy?

YesNo
If yes, please specify
MALE CLIENTS
What is your current shaving system?

Razor / Wet shaveElectricN/A
Do you experience irritation from shaving?

YesNoN/A
The above information is accurate and correct. I understand that if any details about the above information change between successive treatments; it is my responsibility to notify the practitioner.

I understand that I am not obliged to provide personal medical details; however, failure to do so may hinder the outcome or cause adverse effects.

I understand the importance of following home-care instructions given by my practitioner.

I understand the importance of providing correct information to the practitioner to decide on suitability or modification of treatment, and I will review this consultation information at each visit.
Signature*

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Thank you for your patience and willingness to complete this consultation document.

It is essential that we have full disclosure as some treatments carry a risk, and assurance is necessary to determine the proposed treatment is safe and will be successful for you.
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Client Consultation Form

Your Skin

Your Health