New Client Consultation Form

Facial Consultation Form
Date*

MonthDayYear
Name*

First NameLast Name
Date of Birth*
Phone Number

Area CodePhone Number
E-mail*
How did you hear about me?*

Website / Online SearchYelpReferralInstagramOther
If Referral, please list name
If Other, please let me know
Your Skin
What are your skin care goals? *
What are your skin care challenges?*

Wrinkles / Fine LinesHyperpigmentation / Sun DamageAcne / Acne ScarringRedness / RosaceaAgingMelasmaSensitivityOther
Please feel free to go into more detail
Have you ever had a facial or skin treatment before?*

YesNo
If Yes, when?
What Skin Care Products do you currently use?*

Cleanser / Face WashFace Scrub / ExfoliantsTonerSerumsMoisturizerSunscreenEye Product(s)Other
If you are new to skin care please leave blank so we can fill out together once a regimen is set. If you are seeking corrective treatments please detail 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)
Lip Product(s)
Do you/have you used Retin-A, Retinol, Renova, Vita-A, Accutane, Glycolic Acid, Lactic Acid, Mandelic Acid, or other Vitamin A derivitives?*

Yes, currently usingYes, but not within the last 30 daysYes, but not within the last 6 monthsNoNot sure
Please specify which product or type, if you answered 'Yes, currently using' to above.
Have you ever received chemical peels, laser services, or microdermabrasion treatments? *

Yes, within the last monthYes, within the last 2-3 monthsNo
Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks?*

YesNo
Your Health
Have you experienced any of these health conditions in the past or present?*

Hormone ImbalanceCancer / Systemic DiseaseHigh Blood PressureDiabetesHeart problemArthritisAuto-Immune DisordersAsthmaEpilepsy / Seizure DisorderFever BlistersFrequent Cold SoresHIV/AIDSLupusHepatitisClaustrophobiaHeadaches / MigrainesOtherNone
If you checked yes to any of these please provide further information
Are you pregnant or trying to become pregnant?*

YesNoRecently had a baby and am breastfeedingN/A
Do you?*

Wear contact lensesHave a pacemakerHave metal implantsHave body piercingsNo, not Applicable
Any known allergies?*

AspirinTree NutsLatexDairyFruitsVegetablesFragrances / Essential OilsOtherNone
If Other, please specify
Have you used or been prescribed any medications (topical or oral) for acne / acne control?*

YesNo
If yes, please specify what and date last used
Post Facial 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 SPF 30. Sunscreen (with a minimum SPF 15) 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. Enzyme peels, DermaFile, chemical peels 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 24 hour cancellation is required in order to fill the lost appointment time. In the event of cancellations received less than 24 hours prior to appointment, a cancellation fee of 50% will be charged on your next visit. No Shows will be charged 100%*

I understand the reservation and cancellation policies at Spa Daze by Cate and consent to a charge upon next visit if I fail to give 24 hour notice for appointments scheduled.
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
Signature*

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For Cate's Notes, Please do not fill out.
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Facial Consultation Form

Your Skin

Your Health