Skincare Consultation Form

CLIENT CONSULTATION FORM
If you are an established Skintuition Holistic Skincare client, please fill out this form if you have not completed a Client Consultation Form in 2019. Thank you!
Are you an established client? *

Yes No
How did you hear about Skintuition? *
Do you have an appointment scheduled? *

Yes No
A credit card is required to reserve all appointments and will not be charged unless 48 hour notice is not given for late cancellations or appointment no shows. Please note: the credit card you are using to reserve your appointment is not charging for your actual skin treatment. You will need to provide payment at checkout during your visit.

PLEASE NOTE: SKINTUITION HOLISTIC SKINCARE WILL BE RELOCATING TO 9242-B MOSBY STREET, MANASSAS ON 5/1/19
Name *
Date of Birth *

Month Day Year Date Picker Icon
Age *
Email Address *
Phone Number *
What is your occupation?
What is your preferred method of contact? *

Email Text Phone
Mailing Address *
City, State, Zip *
What do you want to accomplish the most? *

Control acne breakouts and improve scarring Keep your skin looking youthful so you age more gracefully Balance your skincare routine to clean up your bathroom counter Give your skin back it's glow Improve your skin discoloration Work together to calm sensitive skin Just relax, not concerned with education and/or skincare product options
What other skincare goals do you have? *
Which of the following skin treatments have you had in the past?

Chemical Peel Dermaplaning Facial IPL (Intense Pulsed Light) Laser Resurfacing LED Light Therapy Microdermabrasion Microcurrent Microneedling NanoPen Infusion Other Not Listed
Do you have any of the following and desire a non-laser treatment option?

Skin Tags Cherry Angiomas Sebaceous Hyperplasia Milia Broken Vessels (Face Only) Seborrheic Keratoses
Below are questions in regards to your medical history which may or may not impact your skin and skin treatment.
Please list any medical conditions
What medications are you currently using?
What supplements are you currently taking?
Are you currently undergoing Cancer treatment?

Yes No
Are you a Cancer survivor?

Yes N/A
Please add any additional information pertaining to Cancer if applicable
Are you pregnant or trying to become pregnant?

Yes No N/A
Do you have hormone related pigmentation such as Melasma?

Yes No Unsure
Have you been diagnosed with Rosacea?

Yes No I think I have it
Do you suffer from Acne?

Yes No Occasional breakouts
Are you currently being seen by a physician for Acne?

Yes No I have in the past
Have you ever used Accutane?

Yes No Unsure
Have you ever had a reaction to skincare products? If so, please explain:
Do you have allergies to:

Aspirin Fragrance Fruits Milk Other Tree Nuts
If your allergy is not listed, please list here:
Do you have a history of cold sores? *

Yes No
Please note: If you are prone to cold sores and experiencing a breakout, you will not be able to receive any facial or waxing service until you are completely healed.
Do you smoke?

Yes No Previous smoker
Have you had Botox or cosmetic fillers within the past 30 days? *

Yes No
Do you have a pacemaker or a seizure disorder? *

Yes No
What skincare products are you currently using in the MORNING? *
What skincare products are you currently using in the EVENING? *
I acknowledge that with any optional skin treatment certain risks are involved and that complications from known or unknown causes could occur. If I am receiving optional skin treatments at Skintuition and I experience any unusual side effects, I will contact Tracy Childs immediately.

I understand that if I purchase a package of treatments or skincare products, individual results vary and I will not be given a monetary refund if I am unsatisfied. I will be offered a credit to use toward other services or products within a reasonable amount of time if proper notification is given.
If photos are taken of you and they could be used to help others, does Skintuition have your permission to use them for marketing? **(You will be compensated with an appropriate gift for your assistance)

Yes No Unsure
ONLINE CANCELLATIONS accepted up to 72 hrs
BEFORE YOUR SCHEDULED APPOINTMENT

APPOINTMENT CHANGES OR CANCELLATIONS WITHIN 72 hrs
of your scheduled appointment,
TEXT (703) 864-7939 and I will handle it for you

$75 NON-REFUNDABLE FEE charged
for LAST MINUTE CANCELLATIONS WITHIN 48 HRS
of scheduled appointment and NO SHOWS
The information I have provided is accurate to the best of my knowledge and I understand the 48 Hour Cancellation Policy *
Please Initial
Emergency Contact *
Relationship *
Emergency Contact Phone Number *
Should be Empty:

CLIENT CONSULTATION FORM