Client Consultation Form

How did you hear about Skintuition? *

If a friend referred you, please share their name

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.

Name *

Date of Birth *

Month Day Year Date Picker Icon

Age *

Email Address *

Phone Number *

What is your preferred method of contact? *

Email Text Phone

Mailing Address *

City, State, Zip *

What is something you LOVE about your skin? *

How often do you receive professional skin treatments?

Monthly Quarterly Rarely Never

What do you want to accomplish by working together? *

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

Out of your skincare goals, what is MOST IMPORTANT to you right now? *

Do you have any of the following?

Skin Tags Cherry Angiomas Sebaceous Hyperplasia Milia Broken Vessels (Face Only) Seborrheic Keratoses

What is your occupation?

What are some things you like to do in your spare time?

Rate your average daily stress level (1 being very low and 5 highest)

1 2 3 4 5

Does stress affect your sleep?

Yes No Sometimes

What do you do to manage stress? Examples: meditation, yoga, exercise, etc.

Do you follow a special diet?

Vegan Vegetarian Keto Gluten Free Gluten + Dairy Free Dairy Free Other Not Listed

How much water do you consume daily?

Very little to none Recommended amount for body weight

Do you have any digestive concerns?

Bloating Excess Gas Constipation Acid Reflux Food Sensitivities

Do you have a history of yeast or urinary tract infections?

Yes No

Please list any medical conditions

Do you have a pacemaker or a seizure disorder? *

Yes No

Do you have allergies to:

Aspirin Fragrance Fruits Milk Other Tree Nuts

If your allergy is not listed, please list here:

Please explain what happens when you are exposed to what you are allergic to if applicable.

What medications are you currently taking?

What supplements are you currently taking?

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 or use a vape pen?

Yes No Previous smoker Sometimes

Do you consume alcoholic beverages?

Yes No Sometimes

Have you had Botox or cosmetic fillers within the past 30 days? *

Yes No

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

If pregnant, when are you due?

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

How dedicated to your at home skincare routine are you?

Very dedicated Somewhat dedicated It's not that important to me

Where do you typically purchase your at home skincare products?

What skincare products are you currently using in the MORNING? *

What skincare products are you currently using in the EVENING? *

Are there skincare products you are currently using that you love? Which ones and why?

Have you ever had a reaction to skincare products? If so, please explain:

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 Holistic Skincare 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.

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 *

CLIENT CONSULTATION FORM