• Botanic Zen Aesthetics Online Skincare Consultation Form

  • Date*
     - -
  • Format: (000) 000-0000.
  • How did you hear about me?*

  • Your Skin

  • What are your skin care challenges?*
  • Have you ever had a facial or skin treatment before?*
  • Rows
  • Rows
  • Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks?*

  • Your Health-Medical History

    (Please check all that apply)
  • Are you under a dermatolgist's or other physican's care?*
  • Have you experienced any of these health conditions in the past or present?*
  • Medications*
  • 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?*

  • Lifestyle Considerations

  • Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)*
  • Do you smoke?*
  • Have you ever experienced claustrophobia? *
  • Please rate your stress level (common stress = job loss, new job, wedding, romantic breakup, death in family or close friend, graduation, difficult home life, long commute, heavily scheduled).*
  • Have you ever had any reaction to any products or anything you have put on your face?*
  • Do you use fabric softener or fabric softener sheets in the dryer?*
  • Do you swim in a chlorinated pool?*
  • Do you work around chemicals, tars, oils, grease, or ink?*
  • Do you work nights?*

  • FEMALE CLIENTS

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

  • MALE CLIENTS

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

  • Informed Consent

  • I* , consent the attached photographs taken of my face to be used for monitoring treatment progress.
    I hearby agree to all of the above instructions and skincare protocol.       
    *   *   Pick a Date*         

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