Skincare Consultation Form

NEW CLIENT FORM
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
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? *
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)
Below are questions in regards to your medical history which may or may not impact your skin. You may opt to share at your initial appointment.
Please list any medical conditions
What medications are you currently using?
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
Have you ever had a reaction to skincare products? If so, please explain:
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
Do you have allergies to:

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

Yes No
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
Which of the following skin treatments have you had in the past?

Chemical Peel Dermal Needling Dermaplane Facial IPL (Intense Pulsed Light) Laser Resurfacing LED Light Therapy Microdermabrasion Microcurrent Rezenerate Osmosis RevitaPen Other Not Listed
What skincare products are you currently using? *
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
48 Hour Cancellation Policy - Unfortunately, last minute cancellations and "no shows" affect other clients from being able to schedule as the time slot has been held. Please respectfully cancel prior to 48 hours to avoid being charged a $75 fee. Appointment "no shows" will also be charged $75. Please cancel your appointment online if it is outside of the 48 hour window and text Tracy at (703) 864-7939 if it is within the 48 hour period. **It will be at her discretion to allow the $75 to be used as a service credit within 7 days.
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:

NEW CLIENT FORM