New Client Forms
Have you been under the care of a physician, dermatologist or other medical professional within the past year?*
Any recent surgery, including plastic surgery?*
If yes, please explain further:
Have you had any piercings, tattoos, or permanent cosmetics?*
If yes, where on your person?
Have you ever had a body spa treatment before?*
Have you had any of these health conditions in the past or present?*
Has your physician discussed concerns about raising your body temperature?*
Do you follow a restricted diet?*
If you do, please specify:
Do you follow a regular exercise program?*
What is your stress level?*
List any medications you take regularly:
List any over the counter medications (including vitamins, herbal supplements, aspirin, etc.) you take regularly:
Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid or Retinol/vitamin A derivative products?*
Have you used any of these products in the last 3 months?*
Have you used an acne medication?*
If yes, when and which drug?
Do you form thick or raised scars from cuts or burns?*
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?*
If yes, describe further:
Do you experience any problems sleeping?*
Do you wear contact lenses?*
Have you been exposed to the sun or used a tanning bed in the last 48 hours?*
How frequently are you exposed to the sun or use a tanning bed?
Do you have any metal implants or wear a pacemaker?*
Have you ever experienced claustrophobia?*
Do you suffer from sinus problems?*
Have you ever had a rash after using any skin care product?*
Have you ever had irritation after using any skin care product?*
Have you ever had peeling after using any skin care product?*
Have you ever had sun sensitivity after using any skin care product?*
Have you ever had a breakout after using any skin care product?*
Have you ever had an allergic reaction to Cosmetics*
Have you ever had an allergic reaction to Medicine*
Have you ever had an allergic reaction to Food*
Have you ever had an allergic reaction to Animals*
Have you ever had an allergic reaction to Sunscreens*
Have you ever had an allergic reaction to Iodine*
Have you ever had an allergic reaction to Pollen*
Have you ever had an allergic reaction to AHAs*
Have you ever had an allergic reaction to Fragrance*
Have you ever had an allergic reaction to Shellfish*
Have you ever had an allergic reaction to Latex*
Have you ever had an allergic reaction to Drugs*
If other, please specify:
Are you taking oral contraceptives? (female clients only)*
If yes, specify (female clients only)
Any recent changes to or from your contraceptive treatment? (female clients only)*
If so, what and when? (female clients only)
Are you pregnant or trying to become pregnant? (female clients only)*
Are you lactating? (female clients only)*
Any menopause problems? (female clients only)*
If yes, please be specific: (female clients only)
Please use this space to complete answers where space was insufficient. (Please include the number of the question)
Does your job require that you work outdoors?*
What would you like to achieve from your treatment today?*
Have you ever had a facial treatment before?*
If yes, please specify when and what treatment:
Which of the following best describes your skin type?*
Have you ever had chemicals peels, laser treatments, or microdermabrasion?*
If yes, was it in the last month?
Do you use Accutane, Retin-A, Renova, Adapalene Hydroxyl Acid or any other Retinol/vitamin A derivative products?*
If yes, please specify what and when last used:
Have you used acne medication?*
If yes, when and which medication?
Have you experienced Botox, Restylane, or collagen injections?*
If yes, please be specific:
List the skin care products you are currently using and list brands if known:
Have you used any hair removal methods in the past six weeks?*
If yes, check all that apply
Do you experience irritation from shaving?*
Do you experience ingrown hairs as a result of hair removal?*
What areas of concern do you have regarding your: Skin*
What areas of concern do you have regarding your: Eyes*
If other, please be specific:
What areas of concern do you have regarding your: Lips*
If other, can you please be specific:
Have you ever had an allergic reaction to any of the following*
If yes, please give specifications:
If other, please list all allergic reactions:
If you use SPF, how often/when?
Have you recently used any self-tanning lotions, creams, or treatments?*
If yes, please be particular:
Have you had any recent tanning bed or sun exposure that changed the color of your skin?*
Are you taking any oral contraceptives?*
Have you experienced any recent changes to or from your contraceptives?*
If yes, please specify what and when:
Are you pregnant or trying to become pregnant?*
Are you experiencing any menopausal symptoms?*
Are you currently undergoing any hormone therapy treatments?*
If you do, please explain:
How many glasses of water do you drink per day? (Please check one)*
How many caffeinated beverages (coffee, tea, soda, etc.) do you consume per day? (Please check one)*
How many alcoholic beverages do you consume per week? (Please check one)*
How many hours of sleep do you get per night? (Please check one)*
Which foods do you consume on a regular basis?*
What does your daily commute look like?*
How often do you travel on a plane?*
How many hours do you spend in front of a screen or digital device?*
Do you exercise on a regular basis?*
Do you smoke cigarettes, vape, or consume other tobacco products?*
May I call you at the provided phone number to confirm future appointments?*
May I contact you via mail/email about future promotions and news?*
Fitzpatrick Classification:*
Recommended Home Skin Care Products: For Daytime:
Recommended Home Skin Care Products: For Nighttime: