Client Consultation Form

Sex* required

Female

Male

Does your job require that you work outdoors?* required

Yes

No

YOUR SKIN CARE: Have you ever had a facial treatment before?* required

Yes

No

Which of the following best describes your skin type?* required

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?* required

Yes

No

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?* required

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** required

Yes

No

Have you used acne medication?

Yes

No

Have you experienced Botox, Restylane or collagen injections?* required

Yes

No

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:* required

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:* required

Dehydrated

Wrinkles

Puffiness

Dark circles

Other

Your lips:* required

Dehydrated

Cracked or chapped lips

Other

Have you ever had an allergic reaction to any of the following:* required

Cosmetics

AHAs

Medication

Fragrance

Food

Shellfish

Animals

Latex

Sunscreens

Drugs

Iodine

Pollen

Other

No Known Allergies

Have you recently used any self-tanning lotions, creams, or treatments?

Yes

No

Have you had any recent tanning bed or sun exposure that changed the color of your skin?* required

Yes

No

Do you exercise on a regular basis?

Yes

No

Do you smoke cigarettes, vape, or consume other tobacco products?

Yes

No

Are you pregnant or trying to become pregnant?

Yes

No

Are you experiencing any menopausal symptoms?

Yes

No

Are you undergoing any hormone replacement therapy treatments?

Yes

No

MALE CLIENTS: Do you experience irritation from shaving?

Yes

No

FUTURE APPOINTMENTS CONTACT: May I call you at the provided phone number to confirm future appointments?* required

Yes

No

May I contact you via mail/email about future promotions and news?* required

Yes

No