Facial Consultation Form

Facial Consultation Form
This consultation card is used to evaluate your individual skin care needs. I will maintain the confidentiality of this information.
Name*

First NameLast Name
Phone Number*
Date of Birth*
MM/DD/YYYY
Gender*

MaleFemaleOther
Your Health
1. Within the last year, have you been under a dermatologist’s or other physician’s care?*

NoYes
If yes, please specify
2. Have you had any health problems in the past or present?*

NoYes
If yes, please specify
3. List any medications, supplements, vitamins, Retin-A, etc. that you take regularly:*
Do you Smoke?*

NoYes
Do you exercise regularly?*

NoYes
Do you follow a strict diet?*

NoYes
7. Do you wear contact lenses?*

NoYes
8. Do you have metal implants, a pacemaker or body piercings?*

NoYes
9. Your level of stress (1-5 being low, 5-10 being high)*

Type option 15-10
10. Do you have any allergies? Latex, nickel, etc.*

NoYes
If yes, please specify
12. Do you sunbathe or use tanning beds?*

Type option 1Yes
13. Do you drink more than 4 caffeinated beverages daily?*

NoYes
14. Have you ever experienced claustrophobia?*

NoYes
Do you have Botox?*

NoYes
If yes, when was your last Botox appointment?
Your Skin
15. What are your specific concerns or challenges with your skin? *
16. Have you had a chemical peel, microdermabrasion, laser or light therapy, and injectable or other cosmetic procedure in the last month?*

NoYes
17. Have you waxed in the last 3 days?*

NoYes
18. Do you use Retin-A, Renova, Adapalene, or any other prescription skin products in the last three months?*

NoYes
19. Have you taken isotretinoin (Accutane) within the last 6-12 months?*

NoYes
20. Are you currently using any products that contain the following ingredients? Select all that apply.

Glycolic AcidLactic AcidExfoliating ScrubVitamin AOther Acid ingredient
21. Do you ever experience these conditions?*

FlakinessTightnessObvious DrynessNo
22. Do you use SPF on your skin?*

NoYes
23. Do you burn easily in moderate sunlight?*

NoYes
24. Have you had any direct sun exposure within the last 48 hours?*

NoYes
25. Do you have a tendency to redness?*

NoYes
26. Do you suffer from sinus problems?*

NoYes
27. Are you prone to cold sores or fever blisters?*

Type option 1Yes
28. Are you currently experiencing a breakout?*

NoYes
29. Do you ever experience burning, itching, or stinging sensations on your skin?*

NoYes
If yes, please specify
30. What skin care products are you currently using? Select all that apply.*

SoapCleanserTonerMoisturizerExfoliatorSerumEye ProductNone
31. Are you taking oral contraception?*

NoYes
32. Are you pregnant or trying?*

PregnantTryingNone
33. Are you lactating?*

NoYes
34. Are you currently menstruating ?*

MenstruatingNo
Additional Appointment Consent
Check Box :)*

I consent and give permission for before and after photos/videos to be taken and posted.I do not consent
Policies
Check box below understanding.*

A $15 deposit is required to book appt via Apple Pay or Venmo (DEPOSIT GOES TOWARDS APPT).Any cancellations or Rescheduling must be made within 24 hours otherwise, no refund for your deposit.If 15 minutes late, your appointment will be canceled and I will reach out to reschedule your appt. No refunds for downpayment. This ensures I stay on schedule and I can provide the best service for you.
I EXCEPT.

♡︎Apple Pay, Venmo, or Cash (After Appontment)
Instagram Handle :)
How did You Hear about me?
I confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. I also acknowledge that in order to keep record of my treatment progress photo records are necessary. My esthetician has authorization to take these photos for progress tracking. These photos may be used in social media, website, or print and my identity can be protected upon request. By signing this I acknowledge and agree to all terms.*

I agree
Add any additional notes here:
Signature*

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Facial Consultation Form

Your Health

Your Skin