Facial Treatment Consultation/Consent New Client
Please fill out this form to help us understand your skin needs and to confirm your consent for facial treatments.
Full Name
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First Name
Last Name
Email Address
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example@example.com
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name & Mobile
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How did you hear about me? (Social media, referral, etc.)
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Skin
Let’s talk about YOU and your skin goals!
What would you consider your skin type?
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Oily
Dry
Combination
Sensitive
What are your skin concerns or challenges?
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Teen or Adult Acne/Breakouts
Age Management
Sensitivity
Fine Lines / Wrinkles
Acne Scaring
Hyperpigmentation / Sun Damage
Excess Oil
Dry / Flaky
Other
Please explain other or in more detail
Do you have sensitive skin, rosacea, or eczema?
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Sensitive Skin
Rosacea
Eczema
None
Please explain your daily morning skin care routine.
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Please explain your daily night skin care routine.
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Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?
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Yes, currently using
Yes, but not within the last 30 days
Yes, but not within the last 6 months
Not sure
No
Please specify which product or type, if you answered 'Yes, currently using' to above.
A few days before your appointment, please stop any use of products with any active ingredients or any exfoliation.
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I understand
Other
Have you received any of these facial services in the last 30 days?
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Waxing
Laser / Electrolysis
Threading
Sugaring
Botox / Dermal Fillers / Facial Injections
Depilatory Cream
None
If you received one of these treatments within the last 30 days, please provide last service date.
-
Month
-
Day
Year
Date
Have you ever received a facial treatment before?
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Yes
No
Health
Have you experienced any of these health conditions in the past or present?
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Asthma
Arthritis
Headaches / Migraines
Heart Problem
Cancer / Systemic Disease
Herpes
HIV / AIDS
Diabetes
Auto-Immune Disorders
High Blood Pressure
Lupus
Hepatitis
Fever Blisters
Pacemaker
Depression/ Anxiety
Hormone Imbalance
Cold Sore (If so and you have one currently, please reschedule)
None
Other
Are you claustrophobic?
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Yes
No
Have you currently taking any prescription / over the counter medications?
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Yes
No
If yes please provide details.
Do you have any allergies or sensitivities? (eg: oils, essential oils, cosmetic ingredients, latex, aspirin, nuts, etc.)
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Yes
No
If yes please provide details.
Do you drink alcohol?
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Yes
No
Social
Do you drink more than 4 caffeinated beverages a day? (eg: tea, coffee, soda, energy drinks)
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Yes
No
Are you a smoker?
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Yes
No
Social
What is your daily water intake? (Glasses / Liters)
*
Are you pregnant, breastfeeding, or trying to become pregnant?
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Breastfeeding
Yes
No
N/A
Any issues with menopause?
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Yes
No
N/A
If yes please provide details.
Would you prefer your appointment silent?
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Yes, I want my appointment silent
No, I don’t want to be silent
I am undecided
Is there anything or other information you would like for me to be aware of?
After your facial, it’s important to give your skin a little extra love to keep that glow going! Try to avoid direct sunlight or UV exposure (including tanning beds) right after your treatment. If you’ll be outside, be sure to apply a broad-spectrum SPF 30 or higher to protect your skin. Some redness or pinkness is completely normal after facial massage, gua sha, or stimulation. It simply means blood flow has been stimulated! The evening after your facial, stick to a gentle routine: cleanse with a mild, non-active cleanser and follow with a soothing moisturizer. Avoid exfoliating products or active ingredients (like acids, retinols, or scrubs) on the day of your treatment to prevent irritation or extra sensitivity. Make sure to change your old pillow case, to a new pillow case before bed. If you ever have questions or concerns about your skin post-treatment, please don’t hesitate to reach out. I’m always here to help your skin heal beautifully and maintain that healthy glow.
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I understand
Cancellation Policy for all current and future appointments: In the event of cancellations received less than 24 hours prior to appointment a cancellation fee equal to the reserved service booking will incur. No Shows will be charged 50% of the service booked. As well as non refundable deposit. If running 15 minutes late or more, appointment may be cancelled.
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I understand
Other
I confirm that the information I’ve provided in this form is complete and accurate to the best of my knowledge. I understand that this information is essential for my esthetician to provide safe and effective treatments and that it replaces any previous verbal or written disclosures. I acknowledge that withholding or providing incorrect information may lead to unwanted skin reactions or contraindications during or after treatment. I understand that temporary redness, sensitivity, or other mild reactions can occur following facial services. I agree to communicate immediately with my esthetician if I experience any discomfort during my treatment so that adjustments can be made. I acknowledge that all services received are voluntary, and I release the esthetician from any liability and assume full responsibility for my participation and results.
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I understand
Other
Client Signature Consent
Submit
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