All Things Aesthetic — Client Consultation & Treatment Record Form
Please complete this confidential consultation form before your appointment. Your responses help us evaluate your needs, identify potential contraindications, and provide a safe and personalized service. Please answer all questions accurately and completely.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Please check any that currently apply to you:
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Diabetes
Epilepsy/seizure disorder
Heart/circulatory condition
High or low blood pressure
Autoimmune condition
Cancer/current cancer treatment
Easy bruising or bleeding
None of the above
Date Of Birth
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-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please explain any conditions selected above or provide other health information that may affect your service:
Please select any skin conditions or concerns you currently experience:
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Acne or frequent breakouts
Rosacea/redness
Hyperpigmentation/dark spots
Melasma
Eczema/dermatitis
Psoriasis
Excessive dryness/dehydration
Excessive oiliness
Sensitive/reactive skin
Broken capillaries
Scarring
None of the above
Which services are you interested in or receiving today?
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Facial/Skin Treatment
Dermaplaning
Chemical Peel
Nano Infusion/Nano Needling/Microneedling
High Frequency/Galvanic Treatment
Facial or Body Waxing
Brow Lamination
Brow Tint
Lash Lift/Perm
Lash Tint
Scalp Treatment
Other
What are your primary skin or beauty goals for today's service?
General Health and Medication History
Please answer each question accurately. Your responses help us identify potential contraindications and provide services safely and appropriately.
Do you have any known allergies or sensitivities?
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Yes
No
If yes, please list or explain your allergies or sensitivities:
Are you currently taking any prescription or over-the-counter medications that may affect your skin, bleeding, healing, or treatment?
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Yes
No
If yes, please list the medication(s) and reason for use:
Are you currently using, or have you recently used, Retin-A/tretinoin, retinol, prescription acne medication, exfoliating acids, or other skin-sensitizing products?
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Yes
No
If yes, please list the product or medication and when you last used it:
Do you have diabetes or another condition that may affect healing?
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Yes
No
If yes, please explain:
Do you have a bleeding or clotting disorder, or do you experience excessive bleeding or bruising?
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Yes
No
If yes, please explain:
Are you currently taking any blood-thinning medications or medications that may increase bleeding or bruising?
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Yes
No
If yes, please list the medication(s):
Do you have a history of delayed wound healing, raised scars, or keloid scarring?
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Yes
No
If yes, please explain:
Do you have a history of cold sores or herpes outbreaks, particularly in the area being treated?
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Yes
No
If yes, please explain the location and approximate date of your most recent outbreak:
Are you currently pregnant, possibly pregnant, or breastfeeding?
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Yes
No
N/A/Prefer not to answer
Do you have any other health condition that could affect your skin, healing, sensitivity, bleeding, or ability to safely receive an aesthetic treatment?
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Yes
No
If yes, please explain:
SKIN HISTORY & CONCERNS
How would you describe your skin type?
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Dry
Oily
Combination
Normal
Sensitive
Unsure
Which skin concerns are you currently experiencing? Select all that apply.
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Acne / Breakouts
Redness / Sensitivity
Excessive Dryness / Dehydration
Excess Oil
Fine Lines / Wrinkles
Uneven Skin Texture
Sun Damage
Enlarged Pores
Loss of Firmness
None
Other
Do you currently have any open wounds, cuts, abrasions, active skin infections, sunburn, significant irritation, or inflamed skin in the area to be treated?
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Yes
No
If yes, please describe the condition and location:
Do you have any known skin allergies, sensitivities, or previous reactions to professional skincare products or treatments?
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Yes
No
If yes, please describe the allergy, sensitivity, product, or previous reaction:
Have you recently received Botox, dermal fillers, laser treatments, chemical peels, dermaplaning, microneedling, waxing, permanent makeup, or another cosmetic/skin procedure?
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Yes
No
If yes, please list the procedure(s) and approximate date(s):
Please list the skincare products you currently use at home, including cleansers, serums, moisturizers, exfoliants, retinol/retinoids, acne products, and sunscreen.
What are your primary skin concerns or treatment goals?
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WAXING HISTORY & SAFETY
Are you currently using retinoids, exfoliating acids, prescription acne products, or other products or medications that may increase skin sensitivity?
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Yes
No
Have you recently received a chemical peel, laser treatment, dermaplaning, or other resurfacing treatment in the area you would like waxed?
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Yes
No
If yes, please describe the reaction and area affected:
If yes, please list the treatment and approximate date:
Have you ever experienced skin lifting, bruising, burns, excessive irritation, or another significant reaction from waxing?
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Yes
No
DERMAPLANING, CHEMICAL PEEL & ENZYME TREATMENT SAFETY
Do you currently have active or significantly inflamed acne in the area to be treated?
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Yes
No
Do you currently have cold sores, an active skin infection, open lesions, sunburn, broken skin, or significant irritation in the area to be treated?
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Yes
No
If yes, please describe the condition and area affected:
Have you ever experienced an adverse reaction to a chemical peel, enzyme treatment, dermaplaning, or other professional exfoliation treatment?
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Yes
No
If yes, please describe the treatment and reaction you experienced:
NANO-NEEDLING / NANO-INFUSION SAFETY
Have you had significant sun exposure, a sunburn, or used a tanning bed recently?
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Yes
No
If yes, please provide the approximate date and describe any current redness, sensitivity, or sunburn:
Have you recently received Botox or other injectables, laser treatment, a chemical peel, microneedling, or another intensive facial or skin treatment?
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Yes
No
If yes, please list the treatment and approximate date:
Do you currently have active inflammation, infection, open or broken skin, cold sores, sunburn, or significant sensitivity in the area to be treated?
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Yes
No
If yes, please describe the condition and area affected:
Have you ever experienced an unusual or adverse reaction to professional serums, facial products, or skin treatments?
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Yes
No
If yes, please describe the product or treatment and the reaction you experienced:
MICRONEEDLING HEALTH & SAFETY
Have you recently received Botox or other injectables, laser treatment, a chemical peel, surgery, permanent makeup, or another procedure in the area you would like treated with microneedling?
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Yes
No
If yes, please list the procedure and approximate date:
Have you ever experienced abnormal healing, significant scarring, keloid formation, infection, or another complication following microneedling, tattooing, permanent makeup, or a similar skin procedure?
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Yes
No
If yes, please describe the procedure and complication you experienced:
Do you have any condition, history, or known circumstance that may increase the risk of complications from a procedure involving exposure to blood or body fluids?
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Yes
No
If yes or unsure, please explain so your practitioner can determine whether additional precautions or medical clearance may be appropriate:
Do you currently have active acne, infection, open wounds, cold sores, sunburn, or significantly irritated/compromised skin in the area to be treated?
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Yes
No
Do you currently use any prescription or over-the-counter topical skin medications or treatments?
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Yes
No
If yes, please list the product/medication and how often you use it:Form element:
Do you currently use Retin-A, tretinoin, retinol, adapalene (Differin), or other vitamin A/retinoid products?
*
Yes
No
If yes, please list the medication and the date you last used it:
Do you have any known allergies or sensitivities to skincare products, cosmetics, medications, latex, adhesives, wax, or other ingredients?
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Yes
No
If yes, please list all known allergies or sensitivities:
Have you experienced any allergic reactions, irritation, burning, swelling, or unusual sensitivity from a previous facial, peel, waxing, brow/lash, or skincare treatment?
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Yes
No
If yes, please describe the reaction and the treatment or product that caused it:
Have you had any recent cosmetic or medical procedures such as Botox, dermal fillers, laser treatments, chemical peels, microneedling, or cosmetic surgery?
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Yes
No
If yes, please list the procedure(s) and approximate date(s):
Have you had excessive sun exposure or used a tanning bed within the past 7 days?
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Yes
No
Do you currently have or frequently experience cold sores (fever blisters/herpes simplex) around the mouth or treatment area?
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Yes
No
If yes, when was your most recent outbreak?
ELECTRICAL MODALITIES & TREATMENT SAFETY
Do you have any metal implants, pacemaker, implanted electrical device, or other electronic medical device?
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Yes
No
If yes, please describe:
Do you have any dental braces, metal dental implants, or other metal in or around the treatment area?
*
Yes
No
If yes, please describe the type and location:
Are you currently pregnant or breastfeeding?
Yes
No
Prefer not to answer
Treatment Consent & Acknowledgment I confirm that the information I have provided on this consultation form is accurate and complete to the best of my knowledge. I understand that esthetic services may cause temporary redness, sensitivity, irritation, swelling, or other reactions. I agree to inform my service provider of any changes to my health, medications, allergies, skin condition, or products I am using before receiving future services.
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I have read, understand, and agree.
Photo & Media Consent I understand that photographs may be taken before, during, or after my service for treatment documentation. I may separately choose whether photographs may be used for educational, website, portfolio, or social media purposes.
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I consent to treatment-record photos and promotional/educational use.
I consent to treatment-record photos only.
I do not consent to photographs.
By signing below, I confirm that I have reviewed the information provided on this consultation form and understand and agree to the acknowledgments and consents I selected above.
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Date of Consultation / Service
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Save
Submit
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Anything Else You’d Like Me to Know?Your comfort and experience are important to me. Please share any additional concerns, preferences, questions, or information you would like me to know before your service.
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