New Client Consultation Form

Skin Care Consultation Form

Information provided here will be kept private and confidential.
Canadian College of Aesthetic Dermatology

BC Academy of Medical Aesthetics and Skin Care | www.BcSkinCareAcademy.com | Port Coquitlam, British Columbia, Canada. | +1 (604) 336-0900 | Accredited by the Canadian Association of Medical Spas and Aesthetic Surgeons | www.camacs.ca |
Privacy Policy

We use the personal information entered herein for the purpose of determining your skin condition and skincare suggestions. We affirm that we do not sell, disclose or share your personal information provided here.
Our Goal:

To Discover Your Skin Care Potentials. To suggest best skin care strategy according to your skin type. To Rediscover Your Skin Care Error. To Unlock the Secrets of Skin Radiance. To Teach you how to Pamper Your Skin. To Nourish, Hydrate, Transform, and Elevate Your Skincare Ritual. Walk you Through to Embrace the Beauty Within because we believe that beauty starts with healthy skin.
The Fee: $25.00 CAD

Payable by | E-transfer to info@cancad.ca | by PayPal | or by Credit
Date*

MonthDayYear
Name*

First NameLast Name
Phone Number*
Format: (000) 000-0000.
E-mail*
example@example.com
Date of Birth

MonthDayYear
Date
How did you hear about me?

Website / Online SearchYelpFacebookReferralOther
If Referral, please list name
Your Skin
Do you consider your skin healthy or needs improvment?
What are your skin care goals? *
What are your skin challenges?*

Wrinkles / Fine LinesHyperpigmentation / Sun DamageAcne / Acne ScarringRedness / RosaceaAgingMelasmaSensitivityPsoriasisHair LossEczemaSkin Rash and ItchinessStretch MarksEyelid or Facial SaggingDark Circles under EyesOther
Name other skin challenges if not listed:
Let's determine your skin type:

Based on Fitzpatrick Scale (Type I, II, III, IV, V or VI)
Your Eye Color:

BlackBrownHazelGreenBlue
Your Natural Hair Color at 18:

BlackBrownBlondeAuburnRed
Your Skin Color:

White, fairMedium white to light brownOlive, moderate brownBrown, dark brownBlack
Your Ethnic Background:
Your skin reaction to sun radiation after 1 hour exposure:

Becomes red, burns, blister, never tansBecomes red, burns, minimal tanningInitial redness then medium tanningBecomes dark brown and tans a lotNever burns, deeply tans
Your goals for Skin Care

Choose as many as applicable
What are your main desired results to achieve?*

Facial Wrinkles / Fine Lines ReductionHyperpigmentation RemovalActive Acne TreatmentRedness / Rosacea ReductionAcne Scar ReductionMelasma TreatmentUnwanted Hair RemovalSpider Vein RemovalDouble Chin Fat ReductionTattoo RemovalBody Contouring Fat ReductionScalp Hair Growth and RestorationFacial Skin Lift & FirmnessMole and Skin Tag RemovalEye Brow / Eyelid sagging LiftEyebrows EnhancementNose Reshaping and ContouringLips EnhancementOther
Name or list other desired results if not listed:
Which of the following treatments you have received in the last 3 months?

Cosmetic Facial BotoxDermal Fillers / Lip FillersTherapeutic BotoxLaser / IPL PhotoFacial or Hair RemovalHIFUMicroneedlingMicrodermabrasion
Other skin care treatments?
Have you ever received a surgical facial operation before?

YesNo
If Yes, specifiy the type of surgery and time?
Let's discover some suitable skin care products for you:

Based on your skin type and condition
What Skin Care Products do you currently use?*

Bar SoapFace Scrub / ExfoliantsTonerSerumsMoisturizerSunscreenEye Product(s)Lip Product(s)
If you are seeking corrective treatments please detail the SPECIFIC products (BRAND & PRODUCT TYPE/NAME) you are currently using so I can best answer any questions on ingredients and help you meet your skin care goals.
Cleanser / Face Wash
Bar Soap
Face Scrub / Exfoliants
Toner
Serums
Moisturizer(s)
Sunscreen
Eye Product(s)
Lip Product(s)
Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?

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

Yes, within the last monthYes, within the last 2-3 monthsNoA while ago
Let's Determine Your Facial Skin Condition:

We will suggest some skin care strategies to suit your needs
How you describe your skin condition?*

Extremely drycombined oily / dryMedium drySmall white / pink bumps when hotExteremly oilyRed PimplesMedium oilyWhite head pimplesBlack head pimplesPainfull pus filled pimples
Describe other skin conditions and concerns:
Attach close up images from the condition (optional but recommended)

Cancelof
Your Health

Your Health Information will assist us to advise best skin care regimen
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/AIDSLupusDepression/AnxietyHepatitisHeadaches / MigrainesOtherNone
Do you?*

Wear contact lensesHave a pacemakerHave metal implantsHave body piercingsNo, not 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
Any known allergies?*

AspirinTree NutsLatexDairyFruitsVegetablesShellfishIodineFragrances / 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
Are you a smoker?

YesNoSocialInhaling secondhand smoke / involuntary / passive smoking
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)

YesNo
Do you drink alcohol?

Yes, regularlyNoOccasionallySocial
Please rate your stress level

LowMediumHigh
Does your occupation involves long hours standing? If yes please explain:
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
Any menopause issues?

YesNoN/A
If yes, please specify
If yes, please specify
MALE CLIENTS
What is your current shaving system?

Razor / Wet shaveElectricN/A
Do you experience irritation from shaving?

YesNoN/A
Your Skin Care Report

It takes 3-5 business days to receive your skin care report
I would like to receive my skin care report by:

E-mailPhone callIn-person at the office (additional charge may apply)Hard copy letter
Disclaimer:

The contents on your skin care consultation report, diagnosed problem, suggested products, information and the treatment suggestions are for informational purposes only and do not constitute medical advice; the content of your report is not intended to be a substitute for professional medical advice, diagnosis, or treatment.
Please select the following:*

I agree to the above Disclaimer.

My Products*

Online Skin Care Consultation

Skin Care Consultation Fee

$25.00CAD Quantity
Item subtotal:$0.00CAD

Total

$0.00CAD

Credit Card

Signature*
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Skin Care Consultation Form

Canadian College of Aesthetic Dermatology

Privacy Policy

Our Goal:

The Fee: $25.00 CAD

Your Skin

Let's determine your skin type:

Your goals for Skin Care

Let's discover some suitable skin care products for you:

Let's Determine Your Facial Skin Condition:

Your Health

Your Skin Care Report

Disclaimer:

Credit Card