New Client Consultation Form

Skin Care Assessment Form

All information is held strictest confidence. At no given point is information disclosed or shared without client’s written consent.
Date*

MonthDayYear
Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Post CodeCountry
Phone Number*
E-mail*
example@example.com
How did you hear about us?*

Website / Online SearchFacebookInstagramReferralOther
If you were referred, please let us know who from
If Other, please let us know
Your Skin
What are your skin goals and objectives? *
What are your skin care challenges?*

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

YesNo
If Yes, when?
What Skin Care Products do you currently use?*

Cleanser / Face WashBar SoapFace Scrub / ExfoliantsTonerSerumsMoisturizerSunscreenEye Product(s)Lip Product(s)MaskTreatment
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.
Cleanser / Face Wash
Soap
Face Scrub / Exfoliants
Toner
Serums
Moisturiser(s)
Sunscreen
Eye Product(s)
Lip Product(s)
Masks or Treatment
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 above
Have you ever received chemical peels, laser services, or microdermabrasion treatments?

Yes, within the last monthYes, within the last 2-3 monthsNo
Have you received any of these services in the last 30 days?

Dermal FillersThreadsAnti-Wrinkle InjectionsLaserSkin TreatmentsNone
If yes, please specify
Your Health
Have you experienced any of these health conditions in the past or present?*

Hormone ImbalanceCancer / Systemic DiseaseHigh Blood PressureDiabetesHeart problemArthritisAuto-Immune DisordersAsthmaEpilepsy / Seizure DisorderFever BlistersHerpesFrequent Cold SoresHIV/AIDSLupusDepression/AnxietyHepatitisHeadaches / MigrainesOtherNone
If you checked yes to any of these please provide further information. If not mark N/A*
Do you?*

Wear contact lensesHave a pacemakerHave metal implantsHave body piercingsNo, not Applicable
Do you take any of the following dietary / health supplements?

MultivitaminVitamin CVitamin D/D3ZincOmega 3 / Fish OilB Complex / B12GarlicCalciumFolic AcidMelatoninCoenzyme Q10BiotinCollagen PowderOther
Any known allergies?*

AspirinTree NutsLatexDairyFruitsVegetablesShellfishIodineFragrances / Essential OilsNoneOther
Have you used or been prescribed any medications (topical or oral) for acne / acne control?

YesNo
If yes, please specify what and date last used
Are you a smoker?

YesNoSocial
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)

YesNo
About how much water do you drink a day?
Have you ever experienced claustrophobia?

YesNo
Please rate your stress level

LowMediumHigh
Please let me know if you would like to learn about natural ways to lower stress levels
FEMALE CLIENTS
Are you taking birth control?

YesNoN/A
If yes, please specify
Are you pregnant or trying to become pregnant?

YesNoRecently had a baby and am breastfeedingN/A
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
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.
I have read the post care instructions and agree to adhere to them*

Yes
Cancellation Policy*

I understand the reservation and cancellation policies at Ai Akinaa, LLC. and understand if I fail to give 24 hour notice for appointments that I will be subject to cancellation fee as per policy.
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 Ai Akinaa, LLC. and it’s affiliates from any and all liability and assume full responsibility thereof.

Yes
Signature*

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Skin Care Assessment Form

Your Skin

Your Health