New Client Consultation Form

Skin Care Consultation Form
Date*

MonthDayYear
Name*

First NameLast Name
Phone Number*
E-mail*
example@example.com
Date of Birth

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
How did you hear about Dwelling Place Skincare?

Website / Online SearchYelpFacebookReferralOther
If Referral, please list name. (We reward referrals!)
If Other, please let me know
Your Skin
What are your skin care goals? *
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? And what type?
Is your lifestyle more indoors or outdoors?*

IndoorsOutdoorsIndoors mainly, but occasionally outdoors
What Skin Care Products do you currently use?*

Cleanser / Face WashBar SoapFace Scrub / ExfoliantsTonerSerumsMoisturizerSunscreenEye Product(s)Lip Product(s)
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
Bar Soap
Face Scrub / Exfoliants
Toner
Serums
Moisturizer(s)
Sunscreen
Eye Product(s)
Lip Product(s)
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 used or been prescribed any medications (topical or oral) for acne / acne control?*

YesNo
If yes, please specify what and date last used
Have you used or been prescribed any medications (topical or oral) for your skin?*

YesNo
If yes, please specify what and date last used
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 / MigrainesRosacea/Eczema/SensitivityNoneOther
Any known allergies?*

AspirinTree NutsLatexDairyFruitsVegetablesShellfishIodineFragrances / Essential OilsOtherNone
If Other, please specify
Are you a smoker?

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

YesNo
Do you drink alcohol?

YesNo
If yes, how often?
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, what kind
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 or any treatment for like IVF/IVI?

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
Upload front view, and 2 side views of cleaned skin.

Cancelof
Signature*

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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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Skin Care Consultation Form

Your Skin

Your Health