Client Consultation Form

Client Consultation Form

There is a separate Informed Consent Form you will sign the day of your treatment. If you are under 18, your parent or guardian will need to sign for you.
Full Name*

First NameLast Name
Birthday*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Occupation?*
Does this job require you to work outdoors?*

NoYes
Email*
example@example.com
What are your goals for this treatment today?*
Skincare History
What skincare products are you currently using? Please be as detailed as possible!*
Is this your first facial?*

NoYes
Do you have any special skin problems or concerns pertaining to your face or body? Please explain if so.*
What type of skin do you feel like you have? Dry, oily, etc.*
Have you ever received injectable treatments (Botox or filler) or invasive treatments (lasers, microneedling, dermal chemical peels, or radiofrequency)?*

NoYes
The above treatments have a certain amount of downtime required before booking a facial. Please check with your provider to confirm your wait period. ADE is not responsible for any issues that may occur due to not following your provider's protocol.*

I agree
Do you tan in a tanning bed?*

NoYes
Do you smoke or vape?*

NoYes
Medical History

Please be as detailed as possible. This information will never be shared with anyone else and is used to give you the safest treatment possible.
Check the conditions that apply to you:

POTSCancerCardiac DiseaseDiabetesHypertensionMetal ImplantsEpilepsyPacemakerEmbolismPhlebitisAutoimmune DisorderThrombosis
Please list any others:
Please check any allergies you may have:

ShellfishMilkSoyHerbalCitrusEggsWheatMushroomsEnvironmentalNutsFishLatex
Please list any others:
Have you had chemotherapy in the last 3 months?*

NoYes
Are you currently pregnant and/or breastfeeding?*

NoYes
Have you used Accutane in the past year?*

NoYes
Do you have a history of Erythema Ab Igne (EAI), a persistent skin rash produced by prolonged or repeatedexposure to moderately intense heat?*

NoYes
Are you currently taking any medications?*

YesNo
Please list all medications you are taking.
How often do you consume alcohol?*

DailyWeeklyMonthlyOccasionallyNever
Do you use any tobacco products?*

YesNo
I certify that the preceding medical, personal, and skin history statements are true and correct. I am aware that it is my responsibility to inform the esthetician of my current medical or health conditions and to update this history. A current medical history is essential to execute appropriate treatment procedures.*

I agree
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Client Consultation Form

Skincare History

Medical History