Skincare Consultation Form

{date}
Skincare Consultation Form
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Post CodeCountry
Phone Number*

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

Website / Online SearchFacebookInstagramOtherAnother 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
Your Skin Goals
What is primary goal for treatment today?*

Wrinkles / Fine LinesHyperpigmentation / Sun DamageAcne / Acne ScarringRedness / RosaceaAgingMelasma (areas of tan/dark skin discoloration)SensitivityOther
Choose the option that best fits your goal:

Develop treatment plan/strategy to address my primary concernOccasional or single visit for a facial treatment or massage.Monthly facial treatments or massage therapy to maintain and/or correct my primary skincare/massage goals
Have you ever had a facial or skin treatment or before?*

YesNo
What is your daily skincare routine? Describe the types/names of products used.
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 usingYes, but not within the last 30 daysYes, but not within the last 6 monthsNoNot sure
Do you use prescription medication applied topically to your skin? Please answer y/n and list medication if used
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 of these services in the last 30 days?*

Dermal FillersThreadsAnti-Wrinkle InjectionsLaserSkin TreatmentsNone
Have you used or been prescribed any medications (topical or oral) for acne / acne control?*

YesNoAccutane in the past 6 monthsTestosterone blocker
If yes, please specify what treatment and the date of last treatment
Have you seen a dermatologist in the past year for a skin exam?
Your Health
Please indicate any medical conditions you are currently receiving treament for*

Cancer / Systemic DiseaseHigh Blood PressureDiabetesHeart problemArthritisAuto-Immune DisordersAsthmaEpilepsy / Seizure DisorderFrequent Cold SoresHIV/AIDSHeadaches / MigrainesThyroid diseaseHormone ImbalanceDental restorationsHepatitisOtherNot being treated for any medical conditions
Do you?*

Have a pacemakerHave metal implantsHave irregular heartbeatHave a seizure disorderHave cancer and am recieving treatments nowrecently had cancer but are currently not receiving treatmentsNo, not Applicable
Please list your medications. (please include oral contraceptives or hormone replacement). If you take no medicine please reply none
Please list supplements you use. If you take no supplements please reply none.
Any known allergies?*

AspirinTree NutsLatexDairyFruitsVegetablesShellfishIodineFragrances / Essential OilsNo known allergiesOther
If yes, please specify what and date last used
Are you a smoker? *

YesNoSocial
Do you drink half your body weight in ounces of water daily?*

YesNo
Please rate your stress level*

LowMediumHigh
Type of exercise you do regularly (at least 1 time per week)

aerobic (HITT classes, orange theory)stretching/barre classesyogaTia Chi or QiGongmeditation/breathing
Please further describe your exercise or stress management routine. Please list any mobility issues in regards to range of motion or chronic pain here
Are you claustrophobic?*

YesNo
FEMALE CLIENTS
Are you pregnant or trying to become pregnant?*

YesNoRecently had a baby and am breastfeedingN/A
Any menopause symptoms?*

YesNoN/A
If yes, please specify
MALE CLIENTS
What is your current shaving system? *

Razor / Wet shaveElectricN/A
Do you experience irritation from shaving?

YesNoN/A
I have honestly and completely completed this form. I understand this information is confidential.

Yes
To help us prepare for your visit please take forward facing photo in good lighting without makeup.
Please verify that you are human*
Signature*

Clear
Date*

MonthDayYear
Should be Empty:

Skincare Consultation Form

Your Skin Goals

Your Health