New Client Consultation Form
Date
*
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Month
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Day
Year
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Name
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First Name
Last Name
Date of Birth
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Mobile Number
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Area Code
Phone Number
E-mail
*
example@example.com
Occupation
*
How did you hear about us?
*
Website / Online Search
Facebook
Instagram
Referral
Others
If Referral, please list name
If Other, please let us know
Preferred Date
*
Online Consultation Schedule
CEEMAPRI SKINCARE
YOUR SKIN OUR CONCERN
What are your skin care goals?
*
Acne Free
Wrinkle Free
Brighter
Younger Looking
What are your skin care challenges?
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Wrinkles / Fine Lines
Hyperpigmentation / Sun Damage
Acne / Acne Scarring
Redness / Rosacea
Aging
Melasma
Sensitivity
Other
Please feel free to go into more detail
Have you ever had a facial or skin treatment before?
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Yes
No
If Yes, when?
What Skin Care Products do you currently use?
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Cleanser / Face Wash
Bar Soap
Face Scrub / Exfoliants
Toner
Serums
Moisturizer
Sunscreen
Eye Product(s)
Lip Product(s)
Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?
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Yes, currently using
Yes, but not within the last 30 days
Yes, but not within the last 6 months
No
Not sure
Please specify which product or type, if you answered 'Yes, currently using' to above.
Have you received any of these hair removal services in the last 30 days?
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Waxing
Sugaring
Threading
Electrolysis / Laser
Depliatory Cream
Shaving
None
If checked, please note last time.
Have you ever received chemical peels, laser services, or microdermabrasion treatments?
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Yes, within the last month
Yes, within the last 2-3 months
No
Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks?
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Yes
No
Your Health
Have you experienced any of these health conditions in the past or present?
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Hormone Imbalance
Cancer / Systemic Disease
High Blood Pressure
Diabetes
Heart problem
Arthritis
Auto-Immune Disorders
Asthma
Epilepsy / Seizure Disorder
Fever Blisters
Herpes
Frequent Cold Sores
HIV/AIDS
Lupus
Depression/Anxiety
Hepatitis
Headaches / Migraines
Other
None
If you checked YES to any of these please provide further information. If not mark, NA
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Do you?
*
Wear contact lenses
Have a pacemaker
Have metal implants
Have body piercings
Not Applicable
Do you take any of the following dietary / health supplements?
Multivitamin
Vitamin C
Vitamin D/D3
Zinc
Omega 3 / Fish Oil
B Complex / B12
Garlic
Calcium
Folic Acid
Melatonin
Coenzyme Q10
Biotin
Other
If other, please list
Any known allergies?
*
Aspirin
Tree Nuts
Latex
Dairy
Fruits
Vegetables
Shellfish
Iodine
Fragrances / Essential Oils
Other
None
If Other, please specify
Have you used or been prescribed any medications (topical or oral) for acne / acne control?
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Yes
No
If yes, please specify what and date last used
Are you a smoker?
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Yes
No
Social
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)
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Yes
No
Have you ever experienced claustrophobia?
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Yes
No
Please rate your stress level
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Low
Medium
High
FEMALE CLIENTS
Are you taking birth control?
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Yes
No
N/A
If yes, what kind
Are you pregnant or trying to become pregnant?
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Yes
No
Recently had a baby and am breastfeeding
N/A
When was your last period?
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Any menopause issues?
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Yes
No
N/A
If yes, please specify
Are you undergoing any hormone replacement therapy?
Yes
No
Post Facial Care/Waxing Instructions: Aerobic exercise and/or vigorous physical activity should be avoided for 48 hours. Direct sunlight exposure is to be avoided immediately following the treatment (including any strong UV light exposure and/or tanning beds). If some sun exposure cannot be avoided first apply a broad spectrum sunscreen of SPF 30. Sunscreen (with a minimum SPF 15) should become part of your daily skin care regimen as skin can potentially become more sensitize to the sun as a result of this treatment. Unless otherwise specified, in the evening following your treatment, cleanse your skin with a mild cleanser and water followed by a non-active moisturizer. Do not apply additional exfoliating ingredients/products the day of your service as over-exfoliation can result in irritation or further sensitivity. Consult your skin care professional before resuming topical treatments. Enzyme peels, DermaFile or DermaDisc 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. DO NOT peel, pick, rub, or scratch your skin at any time, whatsoever. This can potentially cause damage or compromise your results.
*
I have read the post care instructions and agree to adhere to them.
If yes, please specify
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. 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 and I release this skin care professional from liability and assume full responsibility thereof.
Yes
Online Consultation Reservation and Cancellation Policy: 1. A Non-Refundable Online Consultation Fee of 20,000 NG is required. Make payments to this Account Details 0162363918 ceemapri Limited union bank 2. Cancellations or no show until the day of the appointment may be rebooked upon advice of the client, however will be subject again to Patient Evaluation and Triaging and schedule availability. 3. In the event of a second cancellation or no show, only 50% of Online Consultation Fee will be deductible. 4. In the event of a third cancellation or no show, the full amount is waived.
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I understand the reservation and cancellation policies at Ceemapri Skincare
Signature
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