New Client Consultation Form

Date*

MonthDayYear

Name*

First NameLast Name

Date of Birth*

Address*

Street Address

Street Address Line 2

CityState

Post CodeCountry

Phone Number*

Area CodePhone Number

E-mail*

How did you hear about us?*

If you were referred, please let us know who from

If Other, please let us know

What are your skin goals and objectives? *

What are your skin care challenges?*

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?*

Please detail the SPECIFIC products (BRAND & PRODUCT TYPE/NAME) you are currently using so we can best answer any questions on ingredients and help you meet your skin goals.

Cleanser / Face Wash

Soap

Face Scrub / Exfoliants

Toner

Serums

Moisturiser(s)

Sunscreen

Eye Product(s)

Lip Product(s)

Masks or Treatment

Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?*

Please specify which product or type, if you answered 'Yes, currently using' to above

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

Yes, within the last monthYes, within the last 2-3 monthsNo

Have you received any of these services in the last 30 days?*

If yes, please specify

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

If you checked yes to any of these please provide further information. If not mark N/A*

Do you?*

Do you take any of the following dietary / health supplements?

Any known allergies?*

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? *

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

Please let me know if you would like to learn about natural ways to lower stress levels

FEMALE CLIENTS

Are you taking birth control? *

YesNoN/A

If yes, please specify

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

Are you undergoing any hormone replacement therapy?

YesNo

If yes, please specify

MALE CLIENTS

What is your current shaving system? *

Razor / Wet shaveElectricN/A

Do you experience irritation from shaving?

YesNoN/A

Post Treatment Care 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 as over-exfoliation can result in irritation or further sensitivity.
Consult your skin therapist before resuming topical treatments.
Chemical peels or facial waxing 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*

Yes

Cancellation Policy*

I understand the reservation and cancellation policies at Porefection Spa and understand if I fail to give 24 hour notice for appointments that I will be asked for a deposit/my deposit will be forfeited

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 this skin care professional from liability and assume full responsibility thereof.

Yes

Signature*

New Client Consultation Form

Your Skin

Your Health