New Client Consultation Form

Facial Treatment Consultation Form
Name*

First NameLast Name
Phone Number*
E-mail*
example@example.com
How did you hear about me?*

Website / Online Google SearchInstagramFacebookReferralOther
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 / Rosacea / SensitivityAgingBreakoutsDry / FlakyExcess OilOther
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)
Preferred Brand(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 received any of these facial services in the last 30 days?*

WaxingSugaringThreadingElectrolysis / LaserDepliatory CreamBotox / Dermal Fillers / Facial InjectiblesNone
If yes, please confirm last date

MonthDayYear
Date
Your Health
Any known allergies (eg: aspirin, latex, nuts, essential oils)?*

YesNo
If yes, please give details
Is there any other information you would like to make your therapist aware of? If yes, please give details:
After Facial Care Instructions: Avoid direct sunlight exposure immediately after the treatment, including strong UV light and tanning beds. If sun exposure is unavoidable, apply a broad-spectrum sunscreen with at least SPF 30. Unless specified otherwise, in the evening after your treatment, cleanse your skin with a mild cleanser and water, followed by a non-active moisturizer. Avoid using exfoliating ingredients or products on the day of your service to prevent irritation or increased sensitivity. If you experience any concerns after the treatment, please reach out to me.*

I have read the post care instructions and agree to adhere to them.
Signature*

Powered by Jotform SignClear
Should be Empty:

Facial Treatment Consultation Form

Your Skin

Your Health