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New Client Consultation Form
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Client Information:
Name
*
First
Last
Phone
Email
*
Date
Address
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Date of Birth
Occupation
Primary Concerns:
Primary Concerns
*
Blackheads
Fine Lines
Hyper pigmentation
Whiteheads
Wrinkles
Dehydration
Dilated Capillaries
Sagging Skin
Dry Skin
Rosacea / Erythema
Elasticity Loss
Flakiness
Acne
Oily Complexion
Facial Scars
Moles
Eczema/Psoriasis
Aging Skin
Dullness
Warts
PFB-hair/razor bumps
Puffiness/Dark circles under eyes
Hand Spots
Health:
Within the last year, have you been under a physician`s / specialist care?
*
Yes
No
Any medical condition present?
*
Yes (please provide details below)
No
Medical Condition (if Applicable)
Within the last year, have you been under a dermatologist`s care?
*
Yes (please provide details below)
No
Dermatologist's Name (if applicable)
Have you visited a cosmetic surgeon in the past 12 months?
*
Yes
No
Why? (if applicable)
Within the last 12 months, have you undergone any surgery?
*
Yes
No
When? (if applicable)
Where? (if applicable)
Check any health problems you have had in the past or present:
*
Cancer
Diabetes
Epilepsy
Heart problem
Hormone imbalance
Spinal injury
Hysterectomy
Varicose veins
Thyroid condition
AIDS
Systemic disease
Herpes Simplex (cold sore)
High or Low Blood Pressure
Polio
When was your last facial?
Where did you get your last facial? (if applicable)
What kind of facial was it? (if applicable)
List all medications/vitamins/herbs/enzymes/Omega 3 and other supplements you are presently taking.
(Thyroid meds, Steroids, Birth Control, Accutane, Blood thinners, etc.)
Do you wear contact lenses?
*
Yes
No
Do you have facial metal implants or pacemaker?
*
Yes
No
Do you suffer from sinus problems?
*
Yes
No
Lifestyle Information:
What is your level of stress currently?
Selected Value:
0
1 being low, 10 high
2. Do you smoke?
*
Yes
No
How often do you exercise?
(daily, twice a week, 5 days a week, etc.)
If you follow a specific diet, what kind?
How often do you consume sugar?
*
Never
Occassionally
Every day
What type(s) of sugar do you typically consume (if applicable)?
Do you have regular sleep patterns?
*
Yes
No
If you consume dairy products, how often:
(how many per day (if daily), infrequently, etc.)
Do you eat seaweed/shellfish?
*
Yes
No
How often do you eat meat?
*
Never
Occassionally
Every day
Do you salt your food?
*
Yes
No
How would you rate your digestion?
*
Poor
Moderate
Excellent
Your Skin:
What temperature of water do you cleanse your face with?
*
Cool
Warm
Hot
Please list skin care products you currently use on your face.
Cleanser (Brand, Type, How Often?)
Toner, astringent (Brand, Type, How Often?)
Day moisturizer (Brand, Type, How Often?)
Night moisturizer (Brand, Type, How Often?)
Sunscreen (Brand, Type, How Often?)
Topical vitamins (Brand, Type, How Often?)
Specialty serums (Brand, Type, How Often?)
Mask (Brand, Type, How Often?)
Exfoliating scrub/mask/washcloth (Brand, Type, How Often?)
Eye cream (Brand, Type, How Often?)
Prescription products (Brand, Type, How Often?)
Skin Care Devices (Brand, Type, How Often?)
How do you feel about your skin?
What would you like to achieve from your treatment today?
Exfoliation History:
Have you ever had any of the following treatments?
*
Glycolic / AHA peels
Jessner`s peels
Microdermabrasion
Facial implants
TCA peels
Laser on the face
Botox injections
Collagen Injections
In the last month?
*
Yes
No
Do you use any of the following?
*
Renova
Retin A
Accutane
Differin
None
In the last 3 months?
*
Yes
No
Do you use an acne medication?
*
Yes
No
In the last 12 months?
*
Yes
No
If yes, which acne medication?
Are you currently using any products that contain the following ingredients?
*
Glycolic acid
AHA's
Salicylic acid
Vitamin A derivatives
Azelaic acid
When did you exfoliate the last time?
What exfoliant did you use? (if applicable)
Do you wax your face?
*
Yes
No
If yes, where do wax?
If yes, when was the last time you waxed your face?
Moisture Hydration:
How much plain water do you consume daily?
*
How many alcoholic beverages do you consume weekly?
Do you experience these conditions on your skin? (check all that apply)
Flakiness
Tightness
Obvious dryness
What SPF sunscreen do you use on your face?
What SPF sunscreen do you use on your body?
Do you use SPF sunscreen daily?
*
Yes
No
Do you sunbathe?
*
Yes
No
Do you use a tanning booth?
*
Yes
No
Capillary Activity:
Do you burn easily in moderate sunlight?
*
Yes
No
Do you blush easily when nervous?
*
Yes
No
Do you have a tendency to redness?
*
Yes
No
Have you ever experienced a bad sunburn?
*
Yes
No
Where are your ancestors from?
Oil Secretion:
If you ever experience oily shine during the day, where?
T-zone
All over
Do you ever experience skin breakouts?
Yes
No
Occasionally
If yes, where do breakouts typically occur?
Nervous System Activity:
What, if any, caffeinated beverages do you consume?
Coffee
Tea
Soft drinks
How many caffeinated drinks do you consume daily? (if applicable)
Do you ever experience burning or itching sensations on your skin?
Yes
No
If so, what caused it?
What is your pain threshold?
Low
Medium
High
Have you ever experienced claustrophobia?
Yes
No
What type of massage pressure do you prefer?
Soft
Medium
Firm
Have you ever had an allergic reaction to any of the following? (Please read carefully)
Aspirin
Medicine
Iodine
Pollen
Fragrance in face products
Hydroxy acids
Sunscreens
Food
Animals
Essential oils
Cosmetics (M-UP)
Sulfur
BPO (benzoyl peroxide)
Carrier oils (almond, etc.)
Herbal extracts
Skin products reactions
Latex
Other (specify below please)
Other allergic reactions
Female Clients Only (Men please skip to the next section):
Are you taking oral contraception?
Yes
No
Are you pregnant or trying to become pregnant?
Yes
No
Are you lactating?
Yes
No
Do you suffer from PMS?
Yes
No
Have you experienced Menopause?
Yes
No
Are you currently having or due for your menstrual period?
Yes
No
Male Clients Only (Females please skip to the next section):
What is your current shaving system?
Electric
Wet shave
Do you experience irritation from shaving?
Yes
No
Do you experience ingrown hairs?
Yes
No
Rarely
CANCELLATION POLICY
Due to the demand for my services, I require that if you need to cancel your appointment for any reason, you must call at least 48 hours in advance. If you fail to do so, your credit card will be charged for the full amount of your scheduled services. Just as I honor your time, I ask that my lost booking due to late cancellation will be compensated. I appreciate your understanding and cooperation.
Do you understand and agree to the cancellation policy?
*
Agree
No
CONSENT
I confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment.
Digital Signature
Please type your first and last name to consent
Date of consent
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