New Client Consultation Form

Date *

Month Day Year Date Picker Icon

Name *

First Name Last Name

Date of Birth *

Address *

Street Address
Street Address Line 2
City	State
Post Code	Country

Phone Number *

Area Code Phone Number

E-mail *

How did you hear about us? *

Website / Online Search Facebook Instagram Other Another client referred me (tell us who so we can thank them please!)

If you were referred, please let us know who from

If Other, please let us know

What are your skin goals and objectives? *

What are your skin care challenges? *

Wrinkles / Fine Lines Hyperpigmentation / Sun Damage Acne / Acne Scarring Redness / Rosacea Aging Melasma (areas of tan/dark skin discoloration) Sensitivity

Please feel free to go into more detail

Have you ever had a facial or skin treatment before? *

Yes No

What products do you use?

What is your daily skincare routine?

Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives? *

Yes, currently using Yes, but not within the last 30 days Yes, but not within the last 6 months No Not sure

Have you ever received chemical peels, laser services, or microdermabrasion treatments? *

Yes, within the last month Yes, within the last 2-3 months No

Have you received any of these services in the last 30 days? *

Dermal Fillers Threads Anti-Wrinkle Injections Laser Skin Treatments None

If yes, please specify what treatment and the date of last treatment

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

Do you have cancer or recovering from cancer?

Yes No

If you checked yes to any of these please provide further information. If not mark N/A *

Do you? *

Have a pacemaker Have metal implants No, not Applicable

Any known allergies? *

Have you used or been prescribed any medications (topical or oral) for acne / acne control? *

Yes No Accutane in the past 6 months Testosterone blocker

If yes, please specify what and date last used

Are you a smoker? *

Yes No Social

Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks) *

Yes No

Are you claustrophobic? *

Yes No

Please rate your stress level *

Low Medium High

FEMALE CLIENTS

Are you taking birth control? *

Yes No N/A

If yes, please specify

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 Treatment Care Instructions:

Use products recommended by your skincare therapist
Aerobic exercise and/or vigorous physical activity should be avoided for 48 hours.
Direct sun exposure is discouraged. If it cannot be avoided first apply a broad spectrum sunscreen of SPF 30.
Unless otherwise specified, in the evening following your treatment, cleanse your skin with a mild cleanser and water followed by a non-active moisturizer.
Consult your skin therapist before resuming topical treatments.
Chemical peels or facial waxing can result in skin flushing/redness or slight skin flaking or sensitivity for up to 48-72 hours post treatment. If you are alarmed please snap a photo and email it to us with detailed concerns.
DO NOT peel, pick, rub, or scratch your skin at any time, whatsoever. This can potentially cause damage or compromise your results.
Lash lift clients should not get lashes wet/damp or apply cosmetic products for 24-48 hours post treatment as to not compromise the lifting/setting solutions efficacy.

I have read the post care instructions and agree to adhere to them *

Yes

Cancellation Policy *

I understand the cancellation policy is 24 hours. I may be charged the full price of my scheduled visit.

I understand, have read and completed this questionnaire truthfully. 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. I am not promised any result or outcome. I release this skin care professional from liability. I understand signing this agreement is a continued authorization for skincare services valid until I withdraw consent in writing to SkinPro Studio.

Yes

Please verify that you are human *

Signature *

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New Client Consultation Form

Your Skin

Your Health