New Client Skincare Consultation Form

Botanic Zen Aesthetics Online Skincare Consultation Form
Date*

MonthDayYear
Name*

First NameLast Name
Date of Birth*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*
Format: (000) 000-0000.
E-mail*
example@example.com
Website / Online SearchInstagramFacebookReferralOther
If Referral, please list name
If Other, please let me know
Your Skin
What are your skin care goals? *
Wrinkles / Fine LinesHyperpigmentation / Sun DamageAcne / Acne ScarringRedness / RosaceaAgingMelasmaSensitivityOther
Please feel free to go into more detail
YesNo
If Yes, when?

What skin care products do you currently use? 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.*

Rows	Brand + Product Name/Type
Cleanser / Face Wash
Toner
Serums
Moisturizers
Sunscreen
Mask
Foundation
Blush
Exfoliants (acids, serum, scrubs)
Acne Medications
Eye Procucts
Anything Else?

Other Treatments-Have you received any of these treatments in the last 30 days?

Rows	When?	Where?
Chemical Peels
Microdermabrasion
Dermabrasion
Laser Hair Removal
Laser Rejuvenation/Resurfacing
Skin Cancer Removal
Facial Waxing
Electrolysis

YesNo
Your Health-Medical History

(Please check all that apply)
Your Primary Care Physician:
YesNo
If yes, doctor's name?
Hormone ImbalanceDiabetesAuto-Immune DisordersEpilepsy / Seizure DisorderFever BlistersFrequent Cold SoresDepression/AnxietyHepatitisHeadaches / MigrainesEczemaPsoriasisCancerStaph Infection/MRSAHIV/AIDSThyroid ProblemsHysterectomyOvary(ies) RemovedPacemakerHemophiliaLupusAnemiaHigh Blood PressureOtherNone
AntibioticsAccutaneBenzoyl PeroxideRetin ATazoracDifferinAzelexAvitaCleocin-TE-mycin-TCopaxoneCorticosteroidsQuinineAndrostendioneTestosteroneProgesteroneGonadotropinDanzolCyclosporineLithiumIsoniazidImmuranDisulfuramDilantin/TegretolSteroidsMarijuanaOther MedsNone
If you checked yes to any of these please provide further information. If not mark N/A*
MultivitaminVitamin CVitamin D/D3ZincOmega 3 / Fish OilB Complex / B12GarlicCalciumFolic AcidMelatoninCoenzyme Q10BiotinOtherN/A
If other, please list
SulfurAspirinLatexTree NutsDairyFruitsVegetablesShellfishIodineFragrances / Essential OilsOtherNone
If Other, please specify
YesNo
If yes, please specify what and date last used
Lifestyle Considerations
YesNo
YesNoSocial
YesNo
LowMediumHigh
YesNo
YesNo
YesNo
YesNo
Occupation?
YesNo
FEMALE CLIENTS
YesNoN/A
If yes, what kind
YesNoRecently had a baby and am breastfeedingN/A
YesNoN/A
If yes, please specify
MALE CLIENTS
Razor / Wet shaveElectricN/A
YesNoN/A

Botanic Zen Aesthetics Online Skincare Consultation Form

Your Skin

Your Health-Medical History

Lifestyle Considerations

Informed Consent