New Client Consultation Form

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Skincare Consultation Form
Name*

First Name Last Name
Date of Birth*

MonthDay Year
Date
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 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
What is primary reason for seeing us today?*

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

Develop treatment plan/strategy to address my primary skincare concernMaintain my skinOccasional or single visit for a facial treatmentMonthly facial treatments to maintain and/or correct my primary skincare goals
Have you ever had a facial or skin treatment 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 allergies
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
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.
Are you claustrophobic?*

YesNo
Please rate your stress level*

LowMediumHigh
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*

MonthDay Year
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Skincare Consultation Form

Your Skin

Your Health