New Client Consultation Form

New Client Skin Health Intake
Date*

MonthDayYear
Name*

First NameLast Name
Date of Birth*
Address*

Street Address

Street Address Line 2

CityState

Zipcode
Mobile Number*

Area CodePhone Number
E-mail*
example@example.com
Occupation *
How did you hear about us?*

Website / Online SearchFacebookInstagramReferralVagaro SearchOther
If Referral, please list name
If Other, please let us know
Your Skin
What are your skin care goals?*

Improve AcneDecrease WrinklesBrighter ComplexionYounger AppearanceImprove TextureEven Tone
What are your skin care challenges?*

Wrinkles / Fine LinesHyperpigmentation / Sun DamageAcne / Acne ScarringRedness / RosaceaAgingMelasmaSensitivityBlackheads/Large PoresUnder Eye Puffiness/DarknessDullnessBroken CapillariesOther
What would you say your skin type is?*

Normal (no visible blemishes, fine pores, smooth texture)Combination (oily and dry pathces, oily t-zone, hormonal breakouts)Acne (cystic or nodules)Sensitive (reactive to fragrances, often irritated)Oily (large pores, excessive oil)Dry (dull, visible lines and wrinkles, feels tight)Other
Please feel free to go into more detail
Have you ever had a facial or skin treatment before?*

YesNo
If Yes, when?
What Skin Care Products do you currently use?*

Oil CleanserCleanser / Face WashSoapFace Scrub / ExfoliantsAHA'sTonerVitamin C SerumOther SerumsMoisturizerSunscreenEye Product(s)Lip Product(s)
If you are seeking corrective treatments please detail the SPECIFIC products you are using so I can best help you meet your skin care goals. *
Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives or Hydroquinone?*

Yes, currently usingYes, but not within the last 30 daysYes, but not within the last 6 monthsNoNot sure
Please specify which product or type, if you answered 'Yes, currently using' to above.
Have you received any of these hair removal services in the last 30 days?*

WaxingSugaringThreadingElectrolysis / LaserDepliatory CreamShavingNone
If checked, please note last time.
Have you ever received chemical peels, laser services, or microdermabrasion treatments? *

Yes, within the last monthYes, within the last 2-3 monthsNo
How does your skin heal?*

FastSlowScarsPigmentsOther
Do you bruise easily?*

YesNo
Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks?*

YesNo
Your Health
Have you experienced any of these health conditions in the past or present?*

Hormone ImbalanceCancer / Systemic DiseaseHigh Blood PressureDiabetesHeart problemArthritisAuto-Immune DisordersAsthmaEpilepsy / Seizure DisorderFever BlistersHerpesFrequent Cold SoresHIV/AIDSLupusHysterectomyHemophiliaDepression/AnxietyHepatitisPhlebitis/Blood ClotsHeadaches / MigrainesSeborrheaThyroid ConditionTineaDermatitisEczema, Psoriasis, RosaceaOtherNone
If you checked YES to any of these please provide further information. If not mark, NA*
List any medications that you take regularly. Mark NA if none.*
Do you?*

Wear contact lensesHave a pacemakerHave metal implantsHave body piercingsNot Applicable
Do you take any of the following dietary / health supplements?

MultivitaminVitamin CVitamin D/D3ZincOmega 3 / Fish OilB Complex / B12GarlicCalciumFolic AcidMelatoninCoenzyme Q10BiotinOther
If other, please list
What is your sun exposure?*

NeverLightModerateExcessive
Any known allergies?*

AspirinTree NutsLatexDairyGlutenFruitsVegetablesShellfishIodineFragrances / Essential OilsOtherNone
If Other, please specify
Have you used or been prescribed any medications (topical or oral) for acne / acne control?*

YesNo
If yes, please specify what and date last used.
What is your alcohol consumption?*

NoneOccasionallyOnce a weekFew times a weekDaily
Are you a smoker? *

YesNoSocial
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)*

YesNo
Have you ever experienced claustrophobia? *

YesNo
Please rate your stress level*

LowMediumHigh
FEMALE CLIENTS
Are you taking birth control? *

YesNoN/A
If yes, what kind
Are you pregnant or trying to become pregnant?*

YesNoRecently had a baby and am breastfeedingN/A
When was your last period? *
Any menopause issues? *

YesNoN/A
If yes, please specify
Are you undergoing any hormone replacement therapy? *

YesNo
MALE CLIENTS
What is your current shaving system?*

ElectricRazor / Wet ShaveN/A
Do you experience irritation from shaving?*

YesNoN/A
Are you undergoing any hormone replacement therapy? *

YesNo
If yes, please specify
Post Facial Care/Waxing Instructions: Aerobic exercise and/or vigorous physical activity should be avoided for 48 hours. Direct sunlight exposure is to be avoided immediately following the treatment (including any strong UV light exposure and/or tanning beds). If some sun exposure cannot be avoided first apply a broad spectrum sunscreen of SPF 30. Sunscreen (with a minimum SPF 15) should become part of your daily skin care regimen as skin can potentially become more sensitize to the sun as a result of this treatment. Unless otherwise specified, in the evening following your treatment, cleanse your skin with a mild cleanser and water followed by a non-active moisturizer. Do not apply additional exfoliating ingredients/products the day of your service and up to 72 hours, as over-exfoliation can result in irritation or further sensitivity. Consult your skin care professional before resuming topical treatments. Enzyme peels, chemical peels, facial waxing and Microneedling can result in skin flushing/redness or slight skin flaking or sensitivity for up to 48-72 hours post treatment. DO NOT peel, pick, rub, or scratch your skin at any time, whatsoever. This can potentially cause damage or compromise your results.*

I have read the post care instructions and agree to adhere to them.
I acknowledge that my skin might experience temporary irritation, tightness, redness or slight swelling which usually dissipates within 72 hours, depending on skin sensitivity. I agree to contact Krissa immediately if any unexpected events occur in my post treatment skin health. I acknowledge that this treatment is strictly an elective cosmetic procedure and no medical claims have been expressed or implied. I acknowledge that I should avoid the use of Retin-A type products, aggressive exfoliation, waxing, and products containing acids for 3-5 days prior to my facial appointment.*

I understand the post-treatment expectations and pre-treatment products to avoid and agree to adhere to them.
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 Skin Sanctuary, LLC and it's staff from liability and assume full responsibility thereof. I give consent for all future treatments.

Yes
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New Client Skin Health Intake

Your Skin

Your Health