Client Consultation Form
If you have not booked an appointment yet, please head back to the website to secure one! 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 Name
Last Name
Birthday
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Occupation?
*
Does this job require you to work outdoors?
*
No
Yes
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?
*
No
Yes
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)?
*
No
Yes
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?
*
No
Yes
Do you smoke or vape?
*
No
Yes
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:
POTS
Cancer
Cardiac Disease
Diabetes
Hypertension
Metal Implants
Epilepsy
Pacemaker
Embolism
Phlebitis
Autoimmune Disorder
Thrombosis
Please list any others:
Please check any allergies you may have:
Shellfish
Milk
Soy
Herbal
Citrus
Eggs
Wheat
Mushrooms
Environmental
Nuts
Fish
Latex
Please list any others:
Have you had chemotherapy in the last 3 months?
*
No
Yes
Are you currently pregnant and/or breastfeeding?
*
No
Yes
Have you used Accutane in the past year?
*
No
Yes
Do you have a history of Erythema Ab Igne (EAI), a persistent skin rash produced by prolonged or repeatedexposure to moderately intense heat?
*
No
Yes
Are you currently taking any medications?
*
Yes
No
Please list all medications you are taking.
How often do you consume alcohol?
*
Daily
Weekly
Monthly
Occasionally
Never
Do you use any tobacco products?
*
Yes
No
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
Submit
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