Facial Client Form

Facial Client Form

Eternal Reverie Cosmetic Studio
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
Date of Birth*

MonthDayYear
Date
Preferred Pronouns*
How were you referred to us?*
How were you referred to us?*

GoogleInstagramFacebookTikTokFriendOther
Does your job require that you work outdoors?*

NoYes
What would you like to achieve from your treatment today?*
Have you ever had a facial treatment before?*

NoYes
If yes, when?*
Have you ever had a body spa treatment before?*

NoYes
If yes, 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)
Do you have any special skin problems or concerns pertaining to your face or body?*

NoYes
If yes, please specify:*
Have you ever had chemical peels, laser treatments, or microdermabrasion?*

NoYes
If yes, when was the last treatment:*
Do you use Accutane, Retin-A, Renova, Adapalene Hydroxyl Acid or other Retinol/vitamin A derivative products?*

NoYes
If yes, please specify what and when last used:*
Have you used acne medication?*

NoYes
If yes, when and which medication?*
Have you experienced Botox, Restylane, or collagen injections?*

NoYes
If yes, which and how long ago?*
What skin care products are you currently using? (List brands if known)*
Have you used any hair removal methods in the past six weeks? (check all that apply)*

ShavingWaxingElectrolysisPluckingTweezingStringingDepilatoriesOther
What areas of concern do you have regarding your skin? (check all that apply)*

Breakouts/acneSun damageRosaceaFlaky skinSun/liver/brown spotsUneven skin toneExcessive oil/shineDully/dry skinRedness/ruddinessBlackheads/whiteheadsWrinkles/fine linesBroken capillariesDehydratedOther
What areas of concern do you have regarding your eyes? (check all that apply)*

DehydratedDark circlesWrinklesPuffinessOther
What areas of concern do you have regarding your lips? (check all that apply)*

DehydratedCracked/chapped lipsOther
Have you ever had an allergic reaction to any of the following? (check all that apply)*

CosmeticsFragranceAnimalsDrugsAHAsFoodLatexIodineMedicationShellfishSunscreensPollenOther
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?*

NoYes
If yes, please specify:*
Have you had any recent tanning bed or sun exposure that changed the color of your skin?*

NoYes
If yes, please specify:*
How many glasses of water do you drink per day?*

<1 glass1-3 glasses4-7 glasses8+ glasses
How many caffeinated beverages (coffee, tea, soda, etc.) do you consume per day?*

None1-2 drinks3-5 drinks6+ drinks
How many alcoholic beverages do you consume per week?*

I don't drink1-3 drinks4-7 drinks8+ drinks
How many hours of sleep do you get per night?*

<3 hours3-5 hours6-8 hours8-10 hours10+ hours
Which foods do you consume on a regular basis?*

FruitsFishVegetablesGrains/BreadDairy/EggsProcessed SugarCheeseProcessed MeatsPoultry
What does your daily commute look like?*

CarBikePublic TransportWalkI don't commute
How often do you travel on a plane?*

Never1-2 times per year1-2 times per quarterEvery monthEvery week
How many hours do you spend in front of a screen or digital device?*

<3 hours4-6 hours7-9 hours10-12 hours12+ hours
Do you exercise on a regular basis?*

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

NoYes
What are your stress levels on a scale from 1 to 5 (1 = low stress, 5 = high stress)?*
Are you pregnant or trying to become pregnant?*

NoYes
Are you undergoing any hormone replacement therapy treatments?*

NoYes
What temperature would you like the treatment table during your appointment?*

LowLow-MediumMediumMedium-HighHigh
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 esthetician from liability and assume full responsibility thereof.
Signature*
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