New Client Consultation Form

  • Skin Care Consultation

  • Date*
     - -
  • Date of Birth
     - -
  • Format: (000) 000-0000.
  • How did you hear about us?*

  • Your Skin

  • 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?

  • MALE CLIENTS

  • What is your current shaving system?
  • Do you experience irritation from shaving?

  • Post Treatment Care Instructions:

    • Avoid Sun Exposure: Protect your skin from direct sunlight for at least 48 hours post-treatment. Use a broad-spectrum sunscreen with SPF 30 or higher if sun exposure cannot be avoided.
    • Keep Skin Hydrated: Drink plenty of water to keep your skin hydrated from the inside out. Apply a gentle, non-comedogenic moisturizer to the treated area as needed to prevent dryness and promote healing.
    • Avoid Harsh Products: Refrain from using harsh skincare products, exfoliants, or abrasive scrubs on the treated area for at least one week post-treatment. Stick to gentle, non-irritating skincare products to avoid irritation or inflammation.
    • Avoid Touching or Picking: Resist the urge to touch or pick at the treated area to prevent infection or scarring. Let your skin heal naturally without interference.
    • Follow Specific Instructions: If your skincare provider provided specific post-treatment instructions or recommendations, follow them carefully to optimize results and minimize any potential complications.
    • Stay Cool: Avoid activities that may cause excessive sweating or heat exposure, such as strenuous exercise, saunas, or hot tubs, for at least 48 hours post-treatment. Heat can exacerbate inflammation and irritation.
    • Monitor for Side Effects: Keep an eye out for any unusual or adverse reactions, such as excessive redness, swelling, itching, or blistering. If you experience any concerning symptoms, contact your skincare provider immediately.
    • Follow-Up Appointment: Schedule a follow-up appointment with your skincare provider as recommended to assess treatment outcomes, address any concerns, and determine if additional sessions are needed.
  • Should be Empty: