Consultation Form

Date

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How were you referred to us?

Occupation:

Does your job require that you work outdoors?

What would you like to achieve from your treatment today?

Do you have any special information you wish to disclose?

ABOUT YOUR SKINCARE

Have you ever had a facial treatment before?

Have you ever had a body spa treatment before? If so, please specify when and what treatment:

Which of the following best describes your skin type? (Please check one) Type I Fair skin tones—Always burns, never tans, Type II Light skin tones—Burns easily, tans slightly, Type III Fair to olive skin tones—Burns moderately, tans moderately, Type IV Light brown skin tones—Burns slightly, tans easily, Type V Dark brown skin tones—Rarely burns, tans easily, Type VI Dark brown to black skin tones—Never burns, tans easily

What primary skin care concerns do you have? (Check the ones that pertain) Lines/wrinkles, Hyperpigmentation, Pore congestion/breakouts

Have you ever had chemical peels, laser treatments, high frequency, or microdermabrasion?

Have you ever had chemical peels, laser treatments, high frequency, or microdermabrasion in the last month?

Have you used acne medication?

If so what medication?

When?

Have you experienced Botox, Restylane, or collagen injections within the last two weeks?

Have you received microdermabrasion treatment within the last 72 hours?

Have you had any chemical peels/IPL/photo facials within the last 4 weeks?

Have you received chemotherapy within the last 6 months?

Have you received radiation treatment within the last 6 months?

What skin care products are you currently using? (List brands if known)

Cleanser _________________________________

Toner _____________________________________

Day Moisturizer ____________________________

Night Moisturizer ____________________________

Exfoliator _________________________________

Mask _____________________________________

Eye Product _______________________________

SPF/Sunscreen ____________________________

Scrubs ___________________________________

Makeup Products____________________________

Soap ____________________________________

Shower Gels _______________________________

Body Lotions ______________________________

Other _____________________________________

Have you used any hair removal methods in the past six weeks? No Yes (Check all that apply) Shaving Waxing Electrolysis Plucking Tweezing Stringing/Threading Depilatories

Do you experience irritation from shaving?

Do you experience ingrown hairs as a result of hair removal?

What areas of concern do you have regarding your: Skin (Check all that apply) Breakouts/acne, Uneven skin tone, Blackheads/whiteheads, Sun damage, Excessive oil/shine, Wrinkles/fine lines, Rosacea, Dull/dry skin, Broken capillaries, Flaky skin, Redness/ruddiness, Dehydrated, Sun/liver/brown spots

Eyes (Check all that apply) Dehydrated Wrinkles Puffiness Dark circles

Lips (Check all the apply) Dehydrated Cracked/chapped lips

Have you ever had an allergic reaction to any of the following (Check all that apply) If yes, please specify: _________________________________

What SPF do you use on your face? __________________________

How often/when? ________________________

Have you recently used any self-tanning lotions, creams, or treatments? No Yes

If yes, please specify: _________________________________________________________________

Have you had any recent tanning bed or sun exposure that changed the color of your skin? No Yes If yes, please specify: _________________________________________________________________

Health History

Are you currently taking any prescription blood thinners?

Are you taking any oral contraceptives? No Yes

If yes, please specify: _________________________________________________________________

Have you experienced any recent changes to or from your contraceptives? No Yes

If yes, please specify what and when: ____________________________________________________

Are you pregnant or trying to become pregnant?

Are you experiencing any menopausal symptoms? No Yes

If yes, please specify: _________________________________________________________________

Are you currently undergoing any hormone therapy treatments? No Yes

If yes, please specify:

Lifestyle

How many glasses of water do you drink per day?(Please check one) <1 glass, 1-3 glasses, 4-7 glasses, 8+ glasses

How many caffeinated beverages (coffee, tea, soda, etc.) do you consume per day? (Please check one) None, 1-2 drinks, 3-5 drinks, 6+ drinks

How many alcoholic beverages do you consume per week? (Please check one) I don’t drink, 1-3 drinks, 4-7 drinks, 8+ drinks

How many hours of sleep do you get per night? (Please check one) <3 hours, 3-5 hours, 6-8 hours, 8-10 hours, 10+ hours

Which foods do you consume on a regular basis?

What does your daily commute look like?

How often do you travel on a plane? Never 1-2 times per year 1-2 times per quarter Every month Every week

How many hours do you spend in front of a screen or digital device? <3 hours 4-6 hours 7-9 hours 10-12 hours 12+ hours

Do you exercise on a regular basis?

Do you smoke cigarettes, vape, or consume other tobacco products?

What are your stress levels on a scale from 1 to 5 (1 = low stress, 5 = high stress)?
________________________________
_____________________________________

Charmed Rose Esthetics, LLC would be thankful if you choose to agree to before and after photos to be taken. They would be used for online publicity and to be able to witness the improvement/changes throughout the skincare journey.

I, __________________________, give permission to have photos taken.

I, __________________________, grant full rights to use the images resulting from the photography, and any reproductions or
adaptations of the images for publicity or for the ability to witness the improvement/changes throughout the skincare journey.
This might include (but is not limited to), the right to use them in their printed and online publicity, and social
media.

Name of client (printed): ____________________________

Signature

FUTURE APPOINTMENTS/CONTACT

May I call you at the provided phone number to confirm future appointments?

May I contact you via mail/email about future promotions and news?

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 this institution and/or the technician/esthetician/skin care professional from liability and assume full responsibility thereof.

Client Name (Printed): ______________________________

Signature

Date

Form

Client Consultation Form