New Client Consultation Form

Facial Treatment Consultation Form
Today's Date*

MonthDayYear
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

City

Country
Phone Number*
E-mail*
example@example.com
How did you hear about me?*

Website / Online SearchInstagramFacebookReferralOther
If Other, please let me know
Your Skin
What are your skin care goals? *
What are your skin care challenges?*

Wrinkles / Fine LinesHyperpigmentation / Sun DamageAcne / Acne ScarringRedness / Rosacea / SensitivityAgingBreakoutsDry / FlakyExcess OilOther
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?*

Cleanser / Face WashBar SoapFace Scrub / ExfoliantsTonerSerumsMoisturizerSunscreenEye Product(s)Lip Product(s)
Preferred Brand(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 facial services in the last 30 days?*

WaxingSugaringThreadingElectrolysis / LaserDepliatory CreamBotox / Dermal Fillers / Facial InjectiblesNone
If yes, please confirm last date

MonthDayYear
Date
Your Health
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 / MigrainesCovid-19OtherNone
If you checked yes to any of these please provide further information. If not mark N/A*
Do you?*

Wear contact lensesWear hearing aidsNo, not Applicable
Do you take any dietary / health supplements?

YesNo
If yes, please list
Any known allergies (eg: aspirin, latex, nuts, essential oils)?*

YesNo
If yes, please give details
Are you currently taking any prescription / over the counter medications*

YesNo
If yes, please give details
Are you a smoker? *

YesNoSocial
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)*

YesNo
Do you drink alcohol?*

YesNo
What is your daily water intake (glasses / litres)*
Have you ever experienced claustrophobia? *

YesNo
Please rate your stress level*

LowMediumHigh
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
Are you undergoing any hormone replacement therapy?

YesNo
If yes, please specify
Is there any other information you would like to make your therapist aware of? If yes, please give details:
I consent to be filmed or photographed for the purposes of Social Media sharing and publicizing

yesno
I acknowledge that Before & After photos or video may be taken for the purpose of client progress and will be private if consent was not given to share on social media

yes
After Facial Care Instructions: Avoid direct sunlight exposure immediately after the treatment, including strong UV light and tanning beds. If sun exposure is unavoidable, apply a broad-spectrum sunscreen with at least SPF 30. Facial massage, cupping, and gua sha may cause temporary redness or pinkness, which is a normal and positive outcome indicating increased blood flow from the treatment. Cupping may cause skin markings in areas of stagnation, which typically fade within a few days. If you have any concerns about this, please inform me before the treatment. Unless specified otherwise, in the evening after your treatment, cleanse your skin with a mild cleanser and water, followed by a non-active moisturizer. Avoid using exfoliating ingredients or products on the day of your service to prevent irritation or increased sensitivity. If you experience any concerns after the treatment, please reach out to me.*

I have read the post care instructions and agree to adhere to them.
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Facial Treatment Consultation Form

Your Skin

Your Health