• Facial Treatment Consultation Form

  • Today's Date*
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  • Date of Birth*
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  • Format: (000) 000-0000.
  • How did you hear about me?*

  • Your Skin

  • What are your skin care challenges?*
  • Have you ever had a facial or skin treatment before?*
  • What Skin Care Products do you currently use?*
  • Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?*
  • Have you received any of these facial services in the last 30 days?*
  • If yes, please confirm last date
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  • Your Health

  • Have you experienced any of these health conditions in the past or present?*
  • Do you?*
  • Do you take any dietary / health supplements?
  • Any known allergies (eg: aspirin, latex, nuts, essential oils)?*
  • Are you currently taking any prescription / over the counter medications*
  • Are you a smoker? *
  • Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)*
  • Do you drink alcohol?*
  • Have you ever experienced claustrophobia? *
  • Please rate your stress level*

  • FEMALE CLIENTS

  • Are you taking birth control? *
  • Are you pregnant or trying to become pregnant?*
  • Any menopause issues? *
  • Are you undergoing any hormone replacement therapy?
  • I consent to be filmed or photographed for the purposes of Social Media sharing and publicizing
  • Should be Empty: