Facial Consult Form

1
Name* This field is required.
First Name
Last Name
2
Phone Number* This field is required.
Please enter a valid phone number.
3
Date of Birth* This field is required.
mm-dd-yyyy
4
Appointment Date* This field is required.
Date
Month
Day
Year
5
How did you hear about us?* This field is required.
6
Have you had a facial treatment before?* This field is required.
Yes
No
7
Which best describes your skin type?* This field is required.Check all that apply
Normal
Dry
Combination
Oily
Sensitive
8
What areas of concern do you have regarding your skin?* This field is required.(Check all that apply)
Breakouts/ Acne
Blackheads/ Whiteheads
Excessive Oil/ Shine
Rosacea
Broken Capillaries
Redness/ Ruddiness
Sun Spots/ Age Spots
Uneven Skin Tone
Wrinkles/ Fine Lines
Dull/ Dry Skin
Dehydrated
Other
9
Are you currently taking any medications?* This field is required.
Yes
No
10
If you answered yes, please list them below:Skip if you answered "no".
11
Are you currently using any of the following:* This field is required.
YesNo
YesNo
YesNo
Retinol/ Vitamin A
Acne Medication
Heart Medication
Retinol/ Vitamin A
YesNo
YesNo
YesNo
1 of 3
12
If you are on any form of Retinol/ Vitamin A (Tretinoin, Retinoic Acid, etc), please stop at LEAST 1 week before your service.* This field is required.
I will stop as required.
I am not on any form of Retinol/ Vitamin A
13
Do you have any cosmetic, food or drug allergies?* This field is required.
Yes
No
14
If you answered yes, please list them below:Skip if you answered "no".
15
What products do you use in your skincare routine?* This field is required.
Cleanser
Toner
Exfoliant
Serum
Eye Cream
Moisturizer
SPF
16
Select if any of the following conditions apply to you:
Asthma
Epilepsy
Metal Pins or Plates
Pacemaker
High Blood Pressure
Cold Sore/ Fever Blisters
Uncontrolled Diabetes
Migraines
17
Are you pregnant or breast feeding?* This field is required.
Yes
No
18
Have you received Botox/ Filler injectables in the last 2 weeks?* This field is required.
Yes
No
Other
19
* This field is required.Consent: I understand, have read and completed this form truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosure. 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 the esthetician from liability and assume full responsibility thereof. We will not treat clients with: questionable medical conditions, open wounds or sores, infections, recent dental work, healing incisions, etc. I understand that the treatments I receive are not substitution for medical treatment.
Should be Empty: