New Client Consultation Form

Today’s date

MonthDayYear

Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Referred by

Is this your first facial?

What is the reason for your visit today?

What special areas of concern do you have?

Are you presently under a physicians care for any current skin condition or other problem?

Are you pregnant?

Are you taking birth control pills?

If so, what type?

Hormone replacement?

If so, what?

Do you wear contact lenses?

Do you smoke?

Do you often experience stress?

Have you had skin cancer?

Are you now using (or used in the past):

If so, when and for how long?

Are you now using or have you ever used Accutane?

If so, when and for how long?

Do you have acne?

Experience frequent blemishes?

If so, how frequently?

Do you have any Allergies to cosmetics, foods or drugs? If yes, please list

Are you currently taking medications or vitamins oral or topical?: if so, please list

What products do you use presently?

Please check if you are affected by or have any of the following

Please explain above problems or list any other significant issues.

I verify that I have no symptoms of the flu, cold or other virus including Covid-19, or other contagious illnesses or diseases during my time of service.

I understand that the services offered are not a substitute for medical care and any information provided by the therapist is for educational purposes only and not diagnostically prescriptive in nature. I understand that the information herein is to aid the therapist in giving better service and is completely confidential.

SPA POLICIES

1. Professional consultation is required before initial dispensing of products.

2. Our active discount rate is only effective for clients visiting every 4 weeks.

3. We do not give cash refunds.

4. We require a 24-hour cancellation notice.

I fully understand and agree to the above spa policies.

Signature

Facial Consent Form