Embrace Consultation Form

Embrace Consultation Form

Standard online consultation form for Embrace Aesthetics. All fields are optional unless clearly required in the source. Please complete the consultation, skincare, lifestyle, medical, and consent questions as shown in the reference PDF.
Client Information
Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City
State
ZIP
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Sex
How were you referred to us?
Occupation
Does your job require that you work outdoors?
Treatment Goals and Prior Experience
What would you like to achieve from your treatment today?
Have you ever had a facial treatment before?
If yes, when?
Have you ever had a body spa treatment before?
If yes, please specify when and what treatment
Which of the following best describes your skin type?
Skin Conditions and Prior Procedures
Do you have any special skin problems or concerns pertaining to your face or body?
If yes, please specify your skin problems or concerns.
Have you ever had chemical peels, laser treatments, or microdermabrasion?
Have you had any of these treatments in the last month?
Do you use Accutane, Retin-A, Renova, Adapalene, Hydroxyl Acid, or other retinol or vitamin A derivative products?
If yes, please specify which products you use and when you last used them.
Have you used acne medication?
If yes, when did you last use it?
Which acne medication did you use?
Have you experienced Botox, Restylane, or collagen injections?
If yes, please specify the injection type and any relevant details.
Current Skincare Products
Cleanser (brand)
Toner (brand)
Day Moisturizer (brand)
Night Moisturizer (brand)
Exfoliator (brand)
Mask (brand)
Eye Product (brand)
SPF/Sunscreen (brand)
Scrubs (brand)
Makeup Products (brand)
Soap (brand)
Shower Gels (brand)
Body Lotions (brand)
Other skin care products (specify)
Hair Removal, Skin, Eye, and Lip Concerns
Have you used any hair removal methods in the past six weeks?
Hair removal methods used

Other
Other hair removal method (specify)
Skin concerns

Other
Other skin concern (specify)
Eye concerns

Other
Other eye concern (specify)
Lip concerns

Other
Allergies and Sun Exposure
Have you ever had an allergic reaction to any of the following?

Other
If yes, please specify the allergic reaction(s) or details.
Other allergy (specify)
What SPF do you use on your face?
How often or when do you use SPF?
Have you recently used any self-tanning lotions, creams, or treatments?
If yes, please specify self-tanning product(s) or treatment(s).
Lifestyle and Health Habits
Glasses of water per day
Caffeinated beverages per day
Alcoholic beverages per week
Hours of sleep per night
Foods consumed regularly

Other
Daily commute type
Plane travel frequency
Hours per day in front of a screen or digital device
Do you exercise on a regular basis?
Do you smoke cigarettes, vape, or use other tobacco products?
Stress level (1–5)
Hormonal and Related Medical Questions
If yes, please specify
If yes, please specify what and when
If yes, please specify
Contact Permissions and Consent
May I call you at the provided phone number to confirm future appointments?
May I contact you via mail/email about future promotions and news?
Signature and Date
Client Name (Printed)
Client Name (Signature)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Embrace Consultation Form

Client Information

Treatment Goals and Prior Experience

Skin Conditions and Prior Procedures

Current Skincare Products

Hair Removal, Skin, Eye, and Lip Concerns

Allergies and Sun Exposure

Lifestyle and Health Habits

Hormonal and Related Medical Questions

Contact Permissions and Consent

Signature and Date