New Client Consultation Form
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number. By providing your phone number, you consent to receiving SMS messages regarding updates, appointments, and important notifications. Standard messaging rates may apply. You may text STOP to opt out.
Format: (000) 000-0000.
Birth Date
-
Month
-
Day
Year
Date
How did you hear about Angelas Aesthetics?
Health & Medical History
Are you presently under a Doctor's care? (for any reason other than primary check ups)
Please Select
Yes
No
Do you take any medications on a regular basis? (Including any form of birth control)
Please Select
yes
no
Do you have any allergies?
Please Select
yes
no
Have you ever had an allergic reaction to can skin care products?
Please Select
yes
no
If you said "yes" to the questions above please list here:
Have you ever had Herpes? (cold sores)
Please Select
Are you currently being treated with any medication for Herpes?
Please Select
yes
no
Are you taking any perscription strength topical cream? (i.e steroids, Retin-A, Tretinoin, Tazorac, Differin, etc.)
Please Select
yes
no
Have you been on Accutane in the past 6 months?
Please Select
yes
no
Do you have Epilepsy, Diabetes or any other auto-immune disorders?
Please Select
yes
no
Do you have a pacemaker or any metal implants?
Please Select
yes
no
How would you rate your current stress levels? 1 (no stress) 10 (always stressed)
Please Select
1
2
3
4
5
6
7
8
9
10
Have you had any of the following:
Skin Cancer
Dermatitis
Keloid Scarring
Hepatitis
Not applicable
Treatment Goals & Service Interests
Which specific skin service(s) are you interested in after your consultation?
Acne
Chemical Peel
Dermaplaning
Open to professional recommendations
Please describe your skin concerns, goals, and relevant skin history. Include any long-standing or ongoing issues. This information helps us develop an appropriate treatment plan.
What skin care products are you currently using?
Is there any other information regarding your health Angela Aesthetics should know before your treatment?
Client Acknowledgment & Signature
By signing below, I acknowledge that I have read, understood, and answered all questions honestly and to the best of my ability. I understand that no results can be guaranteed, but Angela Aesthetics LLC and its employees work to the best of their abilities to help achieve my goals. I give Angela Aesthetics LLC and its employees my consent for treatment, and I also consent to the use of my images, videos, and/or results for marketing and social media purposes.
Date
-
Month
-
Day
Year
Date
Submit
Submit
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