NEW CLIENT FACIAL CONSULTATION FORM

NEW CLIENT FACIAL CONSULTATION FORM
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name

First NameLast Name
Date Of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
How did you hear about us?

Other
ALL ABOUT MY SKIN
What are my skin concerns? Select all that apply

Other
What are your skin goals

Other
Have you ever had a facial before?
If Yes, When?
What Skincare products do you currently use? Select all that apply

Other
Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?
If your answer is YES please specify which product/brand you are currently using
Have you ever received chemical peels, laser services, fillers,injections or microdermabrasion treatments?
Your Health
Have you experienced any of these health conditions in the past or present?

Other
Please list any additional health history or health conditions below.
Select all that apply to you

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

Other
Any Known Allergies?

Other
Please share any additional allergies below that aren’t listed above.
Have you used or been prescribed any medications (topical or oral) for acne / acne control?
If yes, please specify what and the date last used
Are you a smoker?
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks
Are you claustrophobic?
Please rate your stress level
FEMALE CLIENTS
Are you taking birth control?
If yes, please specify which type of birth control below.
Are you pregnant or trying to become pregnant?
Any menopause issues?
If yes, please specify
MALE CLIENTS
What is your current shaving system?
Do you experience irritation from shaving?
Thank you for choosing Skin By Arlene for your facial treatment.

To protect your skin and ensure optimal results, please follow these guidelines:

First 24–48 Hours
Avoid touching, picking, rubbing, or scratching your skin. This can cause irritation or compromise results.

Aerobic exercise and vigorous physical activity should be avoided for 48 hours.

Avoid hot showers, saunas, steam rooms, and intense sweating.

Do not apply makeup unless advised by your esthetician.

Sun Protection
Avoid direct sun exposure, tanning beds, and strong UV light immediately after treatment.

If sun exposure is unavoidable, apply a broad-spectrum SPF 30 (minimum SPF 15 daily).

Incorporate sunscreen into your daily routine, as your skin may be more sensitive to the sun after treatment.

Wear a wide-brimmed hat for extra protection.

Evening of Treatment

Cleanse your skin gently with a mild cleanser and lukewarm water.

Apply a non-active moisturizer to hydrate and soothe skin.

Do not use any exfoliating ingredients or products on the day of your treatment.

Consult your esthetician before resuming topical treatments such as retinoids or acids.

Chemical peels or facial waxing may cause redness, mild flaking, or sensitivity for 48–72 hours post-treatment.

Slight dryness or peeling is normal—do not peel, pick, or scratch.
Post Care Instructions
Cancellation Policy (SCAN QR CODE TO PAY DEPOSIT)

I acknowledge that there is $25 deposit is required to secure my appointment. I understand the deposit is non-refundable. I acknowledge my deposit can ONLY be applied to one rescheduled appointment if I reschedule at least 48 hours prior to my appointment date. If I fail to reschedule within the 48-hour window my deposit will be forfeited. I acknowledge there is a 10 minute grace period. After 15 minutes a late fee of $10 is applied. Arrival after 20 minutes of the appointment time will result in a canceled appointment and I will require a new deposit to reschedule my appointment.
Treatment Liability Agreement

I acknowledge that all facial treatments are performed to the best ability of the service provider, based on the information I have provided about my health and skin. I have disclosed all relevant medical history, skin conditions, allergies, and sensitivities prior to treatment. I acknowledge that Arlene Reyes is not liable for any damages, injuries, or unexpected reactions that may occur as a result of the treatment. I release the service provider from any responsibility for adverse reactions or side effects that may occur during after my treatment.
Photo & Video Consent. Photos and/or videos may be taken before, during, and after your treatment to document progress and results.These images may be used for social media, marketing, or educational purposes. Your face will not be shown unless you have given explicit permission. Please indicate your preference below
Client Acknowledgement

I understand, have read and completed the entire 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.
Name

First NameLast Name
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

NEW CLIENT FACIAL CONSULTATION FORM

ALL ABOUT MY SKIN

Your Health

FEMALE CLIENTS

MALE CLIENTS