New Client Consultation Form

  • Skin Care Consultation Form

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

  • Your Skin

  • What are your skin care challenges?*
  • Have you ever had a facial or skin treatment before?
  • Is your lifestyle more indoors or outdoors?*
  • What Skin Care Products do you currently use?*

  • 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. 

  • 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 used or been prescribed any medications (topical or oral) for acne / acne control?*
  • Have you used or been prescribed any medications (topical or oral) for your skin?*

  • Your Health

  • Have you experienced any of these health conditions in the past or present?*
  • Any known allergies?*
  • Are you a smoker?
  • Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)
  • Do you drink alcohol?
  • 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 or any treatment for like IVF/IVI?

  • MALE CLIENTS

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

    We treat all of your personal information as confidential and will not share it with others.

    All orders are subject ot acceptance and availability. If the goods ordered are not available, you will be notified by e-mail. You will have the option either to wait until the item is available in stock or you may cancel your order.

    You are responsible to have a complimentary consultation prior to your purchase to ensure that the product you purchased is suitable for your skin type and condition.

    The ingredients of each product are written in the description of product. If you believe that you may be allergic or sensitive to any of the product ingredients, feel free to contact us. Although allergies are uncommon, they are not impossible. Please make sure you disclose to your provider all medications, allergies and treatments that you have had in the last 6 months to ensure expected results.

    Dwelling Place Skincare does require you to contact us when you would like to return an item. We will accept returns of sealed and unopened prodcuts within 14 days of receipt. A full refund will be issued upon receipt of returned items, if found in original condition and untampered with. You will be responsible for the return shipping costs.

     

     

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