Consultation form
General Information
Full Name
*
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Age
Gender:
*
Female
Male
Prefer not to say
Address
*
Street Address Line 2
Email
*
Phone Number
*
Format: 0000-0000000.
Emergency Contact Name:
Emergency Contact Phone Number:
Format: 0000-0000000.
Occupation:
Health Information
Are you currently taking any medications?
*
Yes
No
Please Specify
Do you have any known allergies?
*
Yes
No
Please Specify
Is there any chance you could be pregnant? (For applicable treatments)
*
Yes
No
Have you had any recent surgeries or medical procedures?
*
Yes
No
Please Specify
Have you consumed alcohol or recreational drugs in the last 12 hours?
*
Yes
No
Are you currently experiencing any of the following: fever, cold, or illness?
*
Yes
No
Please Specify
Do you have any health conditions or concerns that may be relevant to the treatment?
*
Yes
No
Please Specify
Services
What service you need:
*
Facials
Massage
Fat Dissolving Injections
Skin Boosters
IV Drips
Waxing
Facials
What are your primary skin concerns or goals?
*
Do you experience any of the following skin issues? (Select all that apply)
*
Dry skin
Oily skin
Combination skin
Acne/Breakouts
Rosacea
Discoloration
Fine lines & wrinkles
Uneven texture
Enlarged pores
Dark under-eye circles
Other
Are you currently using any skincare products or treatments?
*
Yes
No
Please list them:
*
Have you ever had a facial before?
*
Yes
No
When was your last facial treatment?
*
Massages
Do you have any areas of pain, discomfort, or tension?
*
Yes
No
Please specify:
*
Have you been diagnosed with any of the following? (Select all that apply)
*
Arthritis
Epilepsy
Diabetes
Heart or lung disease
Cancer
High or low blood pressure
Varicose veins
Skin conditions
Other
What is the purpose of your massage today? (e.g., relaxation, pain relief, etc.)
*
Fat Dissolving Injections
Are you currently pregnant or breastfeeding?
*
Yes
No
Do you have any history of reactions to injections or cosmetic treatments?
*
Yes
No
Please specify:
*
Are you taking any blood-thinning medications?
*
Yes
No
Do you have any of the following?
*
Liver or kidney issues
Skin infections or wounds in the treatment area
Allergies to injectable ingredients
Other medical conditions
Please specify:
*
What areas would you like to treat?
*
Skin Boosters
Are you currently using any topical skin treatments (e.g., Retinol, Vitamin C)?
*
Yes
No
Please specify:
*
Do you have any history of allergic reactions to skincare or cosmetic products?
*
Yes
No
Please specify:
*
Are you taking any medications that may affect skin healing?
*
Yes
No
Have you had skin booster treatments before?
*
Yes
No
When was your last treatment?
*
What are your goals for this treatment?
*
IV Drips
Have you received IV treatments in the past?
*
Yes
No
When was your last treatment?
*
Do you have any allergies to vitamins, minerals, or medications?
*
Yes
No
Please specify
*
Are you currently dehydrated or have a history of difficulty with IV access?
*
Yes
No
Are you taking any medications or supplements that may interact with IV therapy?
*
Yes
No
Please specify
*
What is your primary goal for the IV drip? (e.g., hydration, energy boost, recovery, etc.)
*
Waxing
Have you ever had waxing treatments before?
*
Yes
No
Did you experience any reactions?
*
Yes
No
Please specify
*
Do you have sensitive skin or any history of reactions to waxing?
*
Yes
No
Are you currently using any topical medications (e.g., Retinol, Acne treatments)?
*
Yes
No
Please specify
*
Do you have any open wounds, cuts, or skin irritation in the treatment area?
*
Yes
No
What areas would you like to wax?
*
Consent and Agreement
I understand that the treatment is not a substitute for medical advice or treatment and confirm that I have provided accurate information to the best of my knowledge.
*
Yes
No
I consent to the treatment and agree to follow all aftercare recommendations.
*
Yes
No
Client's Signature:
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
End
Submit
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