• ACNE PROGRAM CONSULTATION FORM

    Personal & Confidential, please answer all questions honestly!

  • Please take your time filling out these questions below. Please note that every question has to be answered. If it does not apply to you, please write either "n/a or none". Please make sure to answer the questions honestly! This is important so that I can ensure the best home care regimen and treatment plan for your skin.

  • Format: (000) 000-0000.
  • Date of birth*
     - -
  • Are you under the care of a Dermatologist or Specialty Doctor?*

  • Medical History

  • Please check all that apply*
  • Are you allergic to*
  • Do you smoke cigarettes or marijuana? (This is a no judgement zone, these can affect skin which is why it’s applicable) Check all that apply*

  • Please Answer if applicable

    this below section applies to any person who may carry or nurse a baby, or any person who may shave their face.
  • If you use contraceptive birth control (aside from condoms), what has form do you use?
  • Are you currently pregnant or Nursing?
  • Are you currently trying to conceive?

  • Lifestyle Considerations

  • Have you ever had a reaction to a skincare product?*
  • Have you ever had a reaction to a professional treatment?*
  • Do you use Fabric Softener or Fabric Softener sheets in the dryer?*
  • Do you swim in a chlorinated pool?*
  • Do you work around:*
  • Do you work the night shift?*
  • How would you rate the stress level of your job?*
  • Are you currently under a lot of stress AND/OR has a traumatic event happened to you within the last 3 months?*
  • Please select any of these common stress factors*

  • Beauty Products

    You will need to list brand names and item names of  all products  you use regularly. Please write "n/a" if you do not use a given product.

  • Treatment History

    In the last 90 days, have you had any of the following treatments? If so, please say yes and the date. If it doesn’t apply, please put N/A

  • Diet

    This is a no judgement zone! Please accurately complete this section. I recommend writing in your notes/journal the types of food/supplements you eat before your appointment. You can also brainstorm your favorite types of food/supplements you eat or drink on a daily basis. This is extremely important! Any information helps!!
  • Do you consume any of the following on a regular basis?*

  • I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I am aware that it is my responsibility to inform the esthetician/skin care therapist of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof. 

  • Before your initial consultation please read the following important steps to follow: 

    No excessive sun exposure that can lead to sunburns, no tanning beds, etc.No chemical facial treatments within 14 days of your treatment or consultation No facial waxing within 7 days of your consultation or treatmentsDiscontinue any oral or topical prescriptions within 3 days of your consultation or treatmentsDiscontinue any AHA/BHA active ingredients 3 days before your intital consultation these include: Retinol, Salicylic acid, Glycolic acid, Lactic acid, Mandelic acid, Benzoyl Peroxide

  • Cancellation Policy and Late Policies

    I acknowledge that I must adhere to Revival Beauty’s policies. I understand that cancellations must be done with at least 24 hours notice.  Failure to do so will result in 100% charge of the total service cost. I acknowledge that any NO CALL, NO SHOW, will also result in 100% charge of the total service cost. We realize emergencies do happen and will be considered.If you are more than 10 minutes late we cannot guarantee that we will be able to fit your appointment into the schedule and you may not be seen. If we cannot fit you in, there will be a 50% fee charged of the service booked for the missed appoitment. By signing below, I have agreed to all these policies.
  • Date*
     - -
  • Should be Empty: