Skin Care Consultation Form

New Client Intake Form
Name *

First Name Last Name
Date of birth *

Month Day Year
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number *

Area Code Phone Number
E-mail *
Your Skin
What are your skin goals? *
What are your skin challenges? *

Wrinkles / Fine Lines Hyperpigmentation / Sun Damage Acne / Acne Scarring Redness / Rosacea Aging Melasma Sensitivity Other
Please feel free to go into more detail
What Skin Care Products do you currently use? *

Cleanser / Face Wash Bar Soap Face Scrub / Exfoliants Toner Serums Moisturizer Sunscreen Eye Product(s) Lip Product(s)
Please list the specific products (brand & product type/name) you are currently using so I can best answer any questions on ingredients and help you meet your skin care goals.
Cleanser / Face Wash
Bar Soap
Face Scrub / Exfoliants
Toner
Serums
Moisturizer(s)
Sunscreen
Eye Product(s)
Have you ever received chemical peels, laser services *

Yes, within the last month Yes, within the last 2-3 months No
Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks? *

Yes No
Please list any skincare treatments or other services you are interested in.

HydraFacial Carbon (Hollywood) peel Carbon peel for acne Chemical peels Dermaplaning Injectables
Your Health
Have you experienced any of these health conditions in the past or present? *

Hormone Imbalance Cancer / Systemic Disease High Blood Pressure Diabetes Heart problem Arthritis Auto-Immune Disorders Asthma Epilepsy / Seizure Disorder Fever Blisters Herpes Frequent Cold Sores HIV/AIDS Lupus Depression/Anxiety Hepatitis Headaches / Migraines Other None
If you checked yes to any of these please provide further information. If not mark N/A *
Do you? *

Wear contact lenses Have a pacemaker Have metal implants Have body piercings No, not Applicable
Do you take any of the following dietary / health supplements?

Multivitamin Vitamin C Vitamin D/D3 Zinc Omega 3 / Fish Oil B Complex / B12 Garlic Calcium Folic Acid Melatonin Coenzyme Q10 Biotin Other
If other, please list
Any known allergies? *

Aspirin Tree Nuts Latex Dairy Fruits Vegetables Shellfish Iodine Fragrances / Essential Oils Other None
If Other, please specify
Have you used or been prescribed any medications (topical or oral) for acne / acne control? *

Yes No
If yes, please specify what and date last used
Are you a smoker? *

Yes No Social
FEMALE CLIENTS
Are you taking birth control? *

Yes No N/A
If yes, what kind
Are you pregnant or trying to become pregnant? *

Yes No Recently had a baby and am breastfeeding N/A
Any menopause issues? *

Yes No N/A
If yes, please specify
Are you undergoing any hormone replacement therapy?

Yes No
If yes, please specify
MALE CLIENTS
What is your current shaving system? *

Razor / Wet shave Electric N/A
Do you experience irritation from shaving? *

Yes No N/A
Post Facial Treatment Care Instructions: Aerobic exercise and/or vigorous physical activity should be avoided for 48 hours. Direct sunlight exposure is to be avoided immediately following the treatment (including any strong UV light exposure and/or tanning beds). If some sun exposure cannot be avoided first apply a broad spectrum sunscreen of minimum SPF 30. Sunscreen (with a minimum SPF 30) should become part of your daily skin care regimen as skin can potentially become more sensitized to the sun as a result of this treatment. Unless otherwise specified, in the evening following your treatment, cleanse your skin with a mild cleanser and water followed by a non-active moisturizer. Do not apply additional exfoliating ingredients/products the day of your service as over-exfoliation can result in irritation or further sensitivity. Consult your skin care professional before resuming topical treatments. Some skin treatments can result in skin flushing/redness or slight skin flaking or sensitivity for up to 48-72 hours post treatment. DO NOT peel, pick, rub, or scratch your skin at any time, whatsoever. This can potentially cause damage or compromise your results. *

I have read the post care instructions and agree to adhere to them.
Reservation & Cancellation Policy for all current and future appointments: a valid credit card may be required for some appointments. Please do not forget to confirm your appointment when you receive your reminder from Flawless. In the event of cancellations received less than 24 hours prior to appointment Tues-Fri, a cancellation fee of 50% of the reserved service booking will incur; Saturday and Monday cancellations require 48 hour notice. No Shows will be charged 100% *

I understand the reservation and cancellation policies at Flawless Anti-Aging and Laser Clinic and consent to my credit card on file being charged if I fail to give 24 hour notice for appointments scheduled Tuesday through Friday and 48 hours notice for Saturday appointments.
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this skin care professional from liability and assume full responsibility thereof.

Yes
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New Client Intake Form

Your Skin

Your Health