• New Client Consultation Form

    Welcome to Skin Harmony. Please compete this form as thoroughly as possible.
  • Date*
     - -
  •  -
  • How did you hear about me?*

  • Your Skin

  • Which concerns apply to your skin?*

  • What is your primary reason for coming to see me?
  • Have you ever had a facial or skin treatment before?*
  • If "yes" to above, please provide date.
     - -
    2 digit month, 2 digit day, 4 digit year
  • What Skin Care Products do you currently use?*

  • If you checked any of the above, please enter the brand name(s) below. 
    This is not required but will help me to properly address any skin care concerns.  

  • Do/have you used any products containing Retin-A (oral or topical), Retinol, or other Vitamin A derivitives, Tretinoin, Glycolic Acid, Lactic Acid, Mandelic Acid?*
  • Have you received any of these hair removal services in the last 30 days?*
  • Have you ever received chemical peels, laser services, microdermabrasion, microneedling, dermaplaning, or any aggressive skin treatments?*
  • Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks?*

  • Your Health

  • Are you currently or have you ever experienced any of these health conditions?*
  • Do you?*
  • Do you take any of the following dietary / health supplements?
  • Any known allergies?*
  • Have you used or been prescribed any medications (topical or oral) for acne / acne control, such as Accutane, Adapalene, Differen ?*
  • Are you a cigarette/vape smoker?*
  • Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)*
  • Do you suffer from claustrophobia?*
  • Please rate your average stress level*

  • FEMALE CLIENTS

  • Are you taking birth control or have an IUD ?*
  • Are you pregnant or trying to become pregnant?*
  • Are you menopausal?*
  • Are you undergoing any hormone replacement therapy?

  • MALE CLIENTS

  • What is your current shaving system? *
  • Do you experience irritation from shaving? *

  • Release of Liability

  • Cancellations/Late Arrivals/No Shows
  • Should be Empty: