New Client Consultation Form

New Client Consultation Form
Name*

First NameLast Name
Date*

MonthDayYear
Date of Birth*
Address for product shipping*

Street Address

Street Address Line 2

CityState

Post CodeCountry
Phone Number*

Area CodePhone Number
E-mail
How did you hear about us?*

Website / Online SearchFacebookInstagramReferralOther
If you were referred, please let me know who from
Your Skin
Have you ever had a facial or skin treatment before?*

YesNo
Are you interested in customized home care recommendations?

YesNot right nowInterested in relaxation only
What are your skin goals? *
Skincare concerns?*

Hyperpigmentation / Sun damageWrinkles / Fine linesAgingMelasmaSensitivityRedness / InflammationOther
What would you say your skin type is?*

Normal skin (no visible blemishes, fine pores, smooth texture)Acne (cystic or nodules)Sensitivity (reactive to fragrance, often irritated)Dry (dull, visible lines and wrinkles, feels tight)Oily (enlarged pores, excessive oil)Combination (oily and dry patches, oily t-zone, hormonal breakouts)Unsure
What Skin Care Products do you currently use?*

Cleanser / Face WashBar SoapFace Scrub / ExfoliantsTonerSerumsMoisturizerSunscreenEye Product(s)Lip Product(s)MaskTreatmentNone
Do you experience routine breakouts or acne?*

YesNo
Have you been diagnosed with any of the following?*

EczemaRosaceaPsoriasisNone
Have you ever received chemical peels, laser services, or microdermabrasion treatments? *

Yes, within the last monthYes, within the last 2-3 monthsNo
Have you received any of these facial hair removal services in the last 7 days? Please allow 24hrs before & after treatment*

Waxing/sugaringThreadingLaser/ElectrolysisNone
Do you currently use: If yes, discontinue for 72hrs before and after treatment*

AccutaneRetin-APrescribed topical creamNone
Are you currently using any products that contain: If yes, please discontinue for 24hrs before treatment

AHA (glycolic acid, lactic acid, etc.)BHA (salicylic acid)Vitamin A derivative (retinol/retonids)Exfoliating scrubsNone
Do you?*

Wear contact lensesHave a pacemakerHave metal implantsHave body piercingsSmokeConsume AlcoholConsume caffeineFrequent tanning bedsNone
Your Health
Have you experienced any of these health conditions in the past or present?*

COVID 19 or any covid strainHormone ImbalanceCancer / Systemic DiseaseHigh Blood PressureDiabetesHeart problemArthritisAuto-Immune DisordersAsthmaEpilepsy / Seizure DisorderFever BlistersHerpesCold SoresHIV/AIDSLupusDepression/AnxietyHepatitisHeadaches / MigrainesOtherNone
Any known allergies?*

DetergentAspirinTree NutsGlutenLatexDairyAlmondsFruitsVegetablesShellfishIodineFragrances / Essential OilsSeasonal AllergiesNoneOther
Have you ever received any botox or fillers? If so, when? Please allow 2 weeks before treatment
Especially less than 2 weeks
List any medications/supplements you are taking.
Have you ever experienced claustrophobia? *

YesNo
Please rate your stress level*

LowMediumHigh
Are you taking birth control? *

YesNo
Pregnancy*

YesNoRecently had a baby and am breastfeedingN/A
I acknowledge that my skin might experience temporary irriation, tightness, redness, or slight swelling which usually dissipates within 72 hours depending on skin sensitivity.

I acknowledge that if I am allergic to one or more ingredients in the products used, I may experience allergic reactions.

I acknowledge that if I fail to use a minimal sunscreen (SPF45), I am more susceptible to sunburn, skin damage, and hyperpigmentation. I shoud avoid excessive sun exposure.

I acknowledge that this treatment is strictly elective cosmetic procedure and no medical claims have been expressed or implied.

I acknowledge that I should avoid the use of Retin-A products, aggressive exfoliation, waxing, and products containing acids that are not apart of the recommended take-home regimen for 2-4 weeks following treatment.
I have read the post care instructions and agree to adhere to them*

Yes
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 Morning Glow and its staff from liability and assume full responsibility thereof.*

Yes
Signature*
I use social media platforms for promotional purposes. Are you okay with me taking photos/videos during your service?*

YesNo
If answered NO above, Are you okay with me using photo/video if I block out identity? (Ie. zoomed in picture, blocking eyes, blocking tattoos, etc.)

YesNoN/A, answered yes above
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New Client Consultation Form

Your Skin

Your Health