Client Consultation Form
Name*
Date of Birth*
Address*
City*
State*
Zip*
Phone*
Email*
Sex*
Female
Male
How were you referred to us?*
Occupation:*
Does your job require that you work outdoors?*
Yes
No
What would you like to achieve from your treatment today?*
YOUR SKIN CARE: Have you ever had a facial treatment before?*
Yes
No
If yes, please specify when and what treatment:
Which of the following best describes your skin type?*
Type I Fair skin tones—Always burns never tans
Type II Light skin tones—Burns easily tans slightly
Type III Fair to olive skin tones—Burns moderately tans moderately
Type IV Light brown skin tones—Burns slightly tans easily
Type V Dark brown skin tones—Rarely burns tans easily
Type VI Dark brown to black skin tones—Never burns tans easily
Do you have any special skin problems or concerns pertaining to your face or body?*
Yes
No
If yes, please specify:
Have you ever had chemical peels?
Yes
No
Have you ever had laser treatments?
Yes
No
Have you ever had microdermabrasion?
Yes
No
In the last month?*
Yes
No
Do you use Accutane?
Yes
No
Do you use Retin-A?
Yes
No
Do you use any other Retinol/vitamin A derivative products? **Please discontinue the use of these products within 3 to 5 days of your appointment**
Yes
No
If yes, please specify what and when last used:
Have you used acne medication?
Yes
No
If yes, when? And which medication?
Have you experienced Botox, Restylane or collagen injections?*
Yes
No
If yes, when and what time of injection?
What skincare are you using? Cleanser, Toner, Day/Night Moisturizer, Exfoliator, Mask, Eye Product, SPF/Sunscreen, Scrubs, Makeup, Soap, Shower Gels. Body Lotions, Other - List brands if known*
Have you used any hair removal methods in the past six weeks?
Yes
No
If yes, choose any that apply
Shaving
Waxing
Electrolysis
Plucking
Tweezing
Stringing
Depilatories
Other
What areas of concern do you have regarding your skin:*
Breakouts or acne
Uneven skin tone
Blackheads or whiteheads
Sun damage
Excessive oil or shine
Wrinkles or fine lines
Rosacea
Dull or dry skin
Broken capillaries
Flaky skin
Redness or ruddiness
Dehydrated Sun o liver or brown spots
Other
Your eyes:*
Dehydrated
Wrinkles
Puffiness
Dark circles
Other
Your lips:*
Dehydrated
Cracked or chapped lips
Other
Have you ever had an allergic reaction to any of the following:*
Cosmetics
AHAs
Medication
Fragrance
Food
Shellfish
Animals
Latex
Sunscreens
Drugs
Iodine
Pollen
Other
No Known Allergies
If yes, please explain:
What SPF do you use on your face?*
How often/when?
Have you recently used any self-tanning lotions, creams, or treatments?
Yes
No
If yes, kindly explain:
Have you had any recent tanning bed or sun exposure that changed the color of your skin?*
Yes
No
If yes, explain please:
Do you exercise on a regular basis?
Yes
No
Do you smoke cigarettes, vape, or consume other tobacco products?
Yes
No
What are your stress levels on a scale from 1 to 5 (1 = low stress, 5 = high stress)?
Answered yes? Please specify:
If yes, please specify what and when:
Are you pregnant or trying to become pregnant?
Yes
No
Are you experiencing any menopausal symptoms?
Yes
No
Yes? Specify and explain please:
Are you undergoing any hormone replacement therapy treatments?
Yes
No
If so, kindly specify:
MALE CLIENTS: Do you experience irritation from shaving?
Yes
No
If yes, do specify:
FUTURE APPOINTMENTS CONTACT: May I call you at the provided phone number to confirm future appointments?*
Yes
No
May I contact you via mail/email about future promotions and news?*
Yes
No
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