SKYNTROLOGY Skin Consultation Form

Skin Consultation

Let's create your customized skin care system!
We are bringing you the best of both nature and science!
Welcome to SKYNTROLOGY & XHLSKIN🌱

🫧 Our plant-based company has expanded into luxury corrective skincare, led by a Licensed Advanced Esthetician & Alternative Medicine Practitioner.

🫧 We combine botanical science, vegan formulations, and advanced treatments to support acne, hyperpigmentation, hormonal skin concerns, melasma and healthy aging.

🫧 The questions below help us create a fully customized skincare plan designed for your best skin.

We're happy to have your here :)

🫧 Let's get started!
Please take your time answering each question so we can create a treatment tailored just for you.
Date*

MonthDayYear
Date
Please enter your full name.*

First NameLast Name
Email*
example@example.com
Phone Number*
How old are you ?*
Are your pregnant ?*

YesNo
Do you think you have:*

Dry SkinOily SkinCombination SkinNormal SkinHyper-allergenic SkinOther
Do you have any current Skin Medical Conditions ?*

EczemaRosaceaCystic AcneCold SoresPsoriasisNone
Do You Have (select all that apply):*

Sun DamageAge SpotsFine Lines & WrinklesAcne or Large PoresDiscolorationDark Circles or Puffiness Under the EyesAcne scarsHyperpigmentationInflamed or Active AcneOther
Have you’ve had any of the following treatments in the last 6 months ?*

Chemical peelsMicroneedlingDermaplaningBotox or FillersFacialLaserOther
What Would You Like to Change/Improve or Are there any specific areas of concern?*
What are Your Skin Goals?*
What Skincare Products are you Currently Using? (PLEASE BE SPECIFIC)*
Are you taking any photosensitizing medications ?*

YesNo
Are you currently on any medications that may increase sensitivity to light?*

YesNo
Do you consume a lot of dairy or processed foods? *
Have you experienced any of the following reactions to facial treatments or products*

Redness or irritationBreakouts or acne flare-upsItching or burning sensationExcessive dryness or flakingSwelling or puffinessRash or hivesIncreased sensitivity to the sunNo adverse reactionsOther
Do you have any known allergies? (skin or otherwise) Please list below !*
Are there any particular areas you would like us to focus on?*
Sunscreen Use: Do you wear sunscreen daily?*

YesNo
Are you okay with being recorded? (Your Privacy Is our biggest concern)*

YesNoOther
Are you okay with being posted ? (We post before and afters on our social media accounts ; TikTok and Instagram)*

YesNo
Progress photos may be taken and kept in your confidential client file to track your results.
How did you find us ? (TikTok , Instagram , Google etc).*
Lifestyle and Additional Information: How often do you experience skin issues such as breakouts or irritation?*
Are you taking any medications (prescription or over-the-counter) that might affect your skin? (Check all that apply):*

Retinoids (e.g., Retin-A, Tretinoin, Differin, Accutane)Antibiotics (e.g., Doxycycline, Minocycline, Clindamycin)Birth control or hormone therapyBlood thinners (e.g., Aspirin, Warfarin)Steroids (e.g., Prednisone, Hydrocortisone)Anti-inflammatory medications (e.g., Ibuprofen, Naproxen)Antihistamines (e.g., Benadryl, Zyrtec, Claritin)Diabetes medications (e.g., Metformin, Insulin)Thyroid medications (e.g., Levothyroxine)Chemotherapy or immunosuppressive drugsNoneOther
Are you allergic or sensitive to any essential oils ?*
Please note: Corrective treatments such as Chemical Peels and Microneedling are an investment, with individual sessions starting at $250 and corrective packages ranging from $550–$1,800. Treatment recommendations are made after your first appointment.

Deposits for skin packages are submitted online. Final payment is due in person upon esthetician approval.
Investment Awareness: Our Corrective Facial & Advanced treatments range from $200–$450+ depending on your skin goals and treatment plan. Please select the range you’re comfortable investing in for your skin journey:*
Pre-Appointment Details

(Before Your Facial)

*Please take your time to read*

➤ Arrive with a clean face—no makeup, skincare products, or sunscreen.

➤ Avoid exfoliating, retinol, or other active ingredients for 48 hours prior.

➤ Stay hydrated!

➤ Wear comfortable clothing—you’ll be lying down and relaxing.

➤ Eat a light meal beforehand to avoid feeling faint or uncomfortable.

➤ Let me know about any allergies, medications, or recent treatments (like waxing or chemical peels).

➤ Perform all lip, chin, and eyebrow waxing at least 72 hours before your appointment.

➤ For Men that shave: Please shave 72 hours prior to appointment

➤ Please Avoid using any scrubs, acids, actives or retinol products at least 4-7 days prior

• Discontinue Retin-A, Tretinoin, glycolic acid, mandelic acid, or azelaic acid 7 days before your appointment.

• Plan ahead - don't have a invasive facial right before a big event

• Please arrive on time so we can maximize your service & follow all Pre-Care instructions to maximize results

• No advanced services are provided at any stage of pregnancy .

•Laser hair removal must be completed at least 7 days prior.

• No chemical peels or MicroNeedling or any other advanced treatments from other providers within the last 30 days.

• Avoid excessive sun exposure, tanning beds, or sunburn for at least 5–7 days prior to your appointment.

• Do not shave the treatment area the day of your facial; shaving should be done 24–48 hours prior if needed.

• Please inform your provider of any recent illnesses, cold sores, open lesions, or skin infections before your visit.

• Avoid alcohol and blood-thinning supplements (such as fish oil, aspirin, or ibuprofen) 24–48 hours before advanced treatments, unless prescribed by a physician.

• Men should arrive clean-shaven unless otherwise instructed for the service booked.

• Clients currently using oral or topical antibiotics must disclose this prior to treatment.

• If you have a history of keloid scarring, hyperpigmentation, or sensitive skin, please note this on your consultation form.

• Results may vary and mild redness, sensitivity, or peeling may occur following treatment.

I’ll text you 24 hours before or the day of your appointment for confirmation.

Text me when you arrive to let you inside

10 minutes is the earliest you can come inside prior to your appointment.
By signing below, I confirm that I have read and understand the pre- and post-appointment instructions. I understand that not following these instructions may slow my results or affect my treatment outcome.*

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Client Wellness Verification

By signing below, I confirm that I am not currently experiencing any illness, fever, infection, or contagious condition prior to treatment.
Signature*

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Consent & Acknowledgment: • I understand that the information provided is truthful and confidential and will be used solely to customize my facial treatment. • I acknowledge that individual results may vary and that all recommendations are based on the details provided. • I agree to immediately inform my esthetician of any discomfort or adverse reactions during the treatment. • I will notify my esthetician of any changes to my skin condition or overall health.*

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After submitting this form, you may proceed to Step Two for booking your appointment ᥫ᭡.

We hope to see you soon !
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Skin Consultation

Please take your time answering each question so we can create a treatment tailored just for you.

Progress photos may be taken and kept in your confidential client file to track your results.

Please note: Corrective treatments such as Chemical Peels and Microneedling are an investment, with individual sessions starting at $250 and corrective packages ranging from $550–$1,800. Treatment recommendations are made after your first appointment.

Client Wellness Verification

After submitting this form, you may proceed to Step Two for booking your appointment ᥫ᭡.