NEW CLIENT CONSULTATION FORM
Name
*
First Name
Last Name
Birth Date
*
Please select a month
January
February
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April
May
June
July
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October
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December
Month
Please select a day
1
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Day
Please select a year
2026
2025
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1924
1923
1922
1921
1920
Year
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Preferred Gender
*
Female
Male
Non-Binary
Non-Gender Confirming
Other
Preferred Pronouns
*
She/Her
He/Him
They/Them
Other
Occupation
*
Does your job require you do work outdoors?
Yes
No
What would you like to achieve from your treatment?
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YOUR SKIN CARE
Have you ever had a facial treatment done before?
Yes
No
Which of the following best describes your skin type? (Please check one)
Type 1 - Fair skin tones, always burns, never tans
Type 2- Light skin tones, burns easily, tans slightly
Type 3 - Fair to olive skin tones, burns moderately, tans moderately
Type 4 - Light brown skin tones, burns slightly, tans easily
Type 5 - Dark brown skin tones, rarely burns, tans easily
Type 6 - Dark brown to black skin tones, never burns, tans easily
Do you have any special skin problems or concerns pertaining to your face or body?
Yes
No
If yes, please specify
Have you ever had chemicals peels, laser treatments, or microdermabrasion?
Yes
No
In the last month?
Yes
No
Do you use Accutane, Retin-A, Renova, Adapalene Hydroxyl Acid or any other Retinol/vitamin A derivative products?
Yes
No
If yes, please specify what and when last used:
Have you used acne medication?
Yes
No
If yes, when and which medication?
Have you experienced Botox, Restylane, or collagen injections?
Yes
No
If yes, please specify
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SKIN CARE CONTINUED
What skincare products are you currently using? (List brands if known)
Cleanser
Toner
Day Moisturizer
Night Moisturizer
Exfoliator
Mask
Eye Product
SPF/Sunscreen
Scrubs
Soap
Shower Gels
Body Lotion
Other
Have you used any hair removal methods in the past six weeks?
Yes
No
If yes, which method(s)
Shaving
Waxing/Sugaring
Electrolysis
Plucking
Stringing
Depilatories
Other
What areas of concern do you have regarding your: Skin
Breakouts/acne
Sun damage
Rosacea
Flaky skin
Sun/liver/brown spots
Uneven skin tone
Excessive oil/shine
Dull/dry skin
Redness/ruddiness
Blackheads/whiteheads
Wrinkles/fine lines
Broken capillaries
Dehydrated
Other
Eyes
Dehydrated
Dark circles
Wrinkles
Puffiness
Other
Lips
Dehydrated
Cracked/chapped lips
Other
Have you ever had an allergic reaction to any of the following (Check all that apply)
Cosmetics
AHAs
Medication
Fragrance
Food
Shellfish
Animals
Latex
Sunscreens
Drugs
Iodine
Pollen
Aspirin
Other
What SPF do you use and how often do you use it?
Have you recently used any self-tanning lotions, creams, or treatments?
Yes
No
If yes, please specify
Have you had any recent tanning bed or sun exposure that changed the color of your skin?
Yes
No
If yes, please specify
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HEALTH HISTORY
Are you taking any oral contraceptives?
Yes
No
If yes, please specify
Have you experienced any recent changes to or from your contraceptives?
Yes
No
If yes, please specify
Are you pregnant or trying to become pregnant?
Yes
No
Are you experiencing any menopausal symptoms?
Yes
No
If yes, please specify
Are you currently undergoing any hormone therapy treatments?
Yes
No
If yes, please specify
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LIFESTYLE
How many oz of water do you drink daily?
How many caffeinated beverages (coffee, tea, soda, etc.) do you consume per day?
None
2 drinks
3-5 drinks
6+ drinks
How many alcoholic beverages do you consume per week?
I dont drink
1-3 drinks
4-7 drinks
8+ drinks
How many hours of sleep do you get per night?
3-5 hours
6-8 hours
8-10 hours
10+ hours
Which foods do you consume on a regular basis?
Fruits
Vegetables
Dairy
Eggs
Poultry
Fish
Grains/Bread
Processed Sugar
Processed Meats
What does your daily commute look like?
Car
Bike
Public Transport
Walk
I dont commute
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 or less
4-6 hours
7-9 hours
10-12 hours
12+ hours
Do you exercise on a regular basis?
Yes
No
Do you smoke cigarettes, vape, or consume other tobacco products?
Yes
No
What are your stress levels on a scale from 1 to 5 (1 = low stress, 5 = high stress)?
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FUTURE APPOINTMENTS/CONTACT
May I call/text you at the provided phone number to confirm future appointments?
Yes
No
May I contact you via mail/email about future promotions and news?
Yes
No
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DISCLOURSURE
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.
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