Consultation Form
Let me get to know you! The more info the better - Please also send over photos of your skin and products you use at home! X
Full Name
First Name
Last Name
Contact Number
Please enter a valid phone number.
Email Address
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
-
Month
-
Day
Year
Date
Referred by:
Please list any medical conditions or health problems you've had past or present:
Please list any medications you use regularly, including any supplements vitamins, accurate, and any other skincare medications:
Do you have any allergies, including to any cosmetics, latex, or medicines? if yes, please specify.
Have you been under care of a physician or dermatologist within the past year? If yes, please specify.
Are you pregnant, nursing or attempting to become pregnant?
Type Yes
Typ No
Do you have any piercings or metal implants?
Yes
No
How many hours of sleep do you get a night?
What's your occupation?
Do you use or have you used a vitamin A skincare products such as Resin A, RRenova, Differin, Tretinoin, Epiduo, or any other retinol, retinal, retinoid product within the last 3 months?
For your consult, you are encouraged to bring in all your skincare products for us to build you a routine
I will bring them!
Not this time
How much UV exposure do you get?
Very little, I'm an indoor person.
A lower amount, I like to be outside sometimes.
A lot. Im outside everyday.
I use tanning beds wherever I can.
How is your sunscreen usage?
I apply it everyday and reapply every 2 hours.
I apply it in the morning before I go out.
I wear it only when I'm outside for long enough.
I hardly wear sunscreen
I don't wear sunscreen.
To protect your skin after your facial, Cleanseē advises diligent sunscreen usage.
I will wear the sunscreen!
You may be recommended Fish oils to help with your skins oil quality - Cleanseē will educate you on why:
I will take recommend Internal fish oil where recommended
Do you pick at your skin or pop your own pimples?
Has a skincare product ever made your skin burn or sting?
Yes
No
Do you wear foundation and concealer? How often? What products and brands? How much coverage?
Have you had Botox or filler injections within the last 3 months? If yes, please specify.
What are your main skin concerns?
How would you rate your skincare knowledge; beginner, intermediate, advanced? Please explain.
When was the last time you had a facial?
Are you experiencing pain in any area of your body currently?
Are you claustrophobic?
Yes
No
What is your main purpose for getting a facial? Select all that apply.
For a skin cancer other than acne
To relax and be pampered
To get ready for an event
To help clear my acne
Lymphatic Drainage
TMJ paid/ tighness
Skin education
What is your current skincare routine? Be specific about products and usage:
What's you skin Type?
Normal
Dry
Oily
Unsure
How would you describe your Fitzpatrick skin type? (Natural colour of your skin/ tolerance to the sun
Type 1: Very fair skin, Red/ Blond hair, always burns
Type 2: Fair/Medium skin, sometimes burns, usually tans
Type 3: Medium to Olive skin, rarely burns, tans easily
Type 4: Medium to deep skins, rarely burns, tans easily
Type5: Deep skin tone very early burns, always tans
Type 6: Very deep skin tone, NEVER burns, deeply pigmented
f your main concern is acne, what have you tried in the past to manage it? What helped? what didn't?
Does your face get red easily?
Do you have a budget I need to be mindful of when recommending products? Please give a price range
Is there anything additional you'd like me to know?
Would you like product recommendations after your facial?
Yes please!
No, Thank you
I'll let you know - case by case
I agree to my before & after photos/videos being used for content and advertising by Cleanseē Studio
Yes, No problem
No or hide my eyes
I consent to Buccal massage
Yes!
No Thank you
By signing this form, I agree that I have given an accurate account of my medical history, including all known allergies and use of prescription medications.I have read and agree to the terms of the Cleanseē Studio Cancellation Policy.
I have have completed this consent form honestly and to the best of my knowledge. I understand that it is possible to experience minor itching, hives, and/or redness. If symptoms persist for more than 2 days or if I’m worried, I will contact my Skin Therapist for guidance. I understand that I’m not to pick, squeeze or agitate my skin during the healing process. I understand that I should avoid strenuous exercise, direct UV exposure, excessively hot showers, baths or sauna, swimming in chlorinated water or the ocean for upto 48hrs. I understand that I should avoid any further skin treatments (excluding a gentle treatment 3-5 days post Skin Needling) including cosmetic tattooing, cosmetic injectables, microdermabrasion, chemical peels for at least 2 weeks. I understand that I am to use gentle skincare for 2-3 days post treatment, avoiding any acids & retinols. If I’m unsure of what to use on my skin, I will contact my Skin Therapist for guidance.
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