New Client Consultation Form

Name*

First Name Last Name

Date of Birth*

Address*

Street Address City State Postcode Country

Phone*

Email*

How did you hear about me?*

Website / Online Search
Yelp
Facebook
Referral
Other

If Referral, please list name

If Other, please let me know

Your Skin

What are your skin care goals?*

What are your skin care challenges?

Wrinkles / Fine Lines
Hyperpigmentation / Sun Damage
Acne / Acne Scarring
Redness / Rosacea
Aging
Melasma
Sensitivity
Other

Please feel free to go into more detail

Have you ever had a facial or skin treatment before?*

Yes
No

If Yes, when?

What Skin Care Products do you currently use?*

Cleanser / Face Wash
Bar Soap
Face Scrub / Exfoliants
Toner
Serums
Moisturizer
Sunscreen
Eye Product(s)
Lip Product(s)

If you are seeking corrective treatments please detail the SPECIFIC products (BRAND & PRODUCT TYPE/NAME) you are currently using so I can best answer any questions on ingredients and help you meet your skin care goals.

Cleanser / Face Wash

Bar Soap

Face Scrub / Exfoliants

Toner

Serums

Moisturiser(s)

Sunscreen

Eye Product(s)

Lip Product(s)

Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?*

Yes, currently using
Yes, but not within the last 30 days
Yes, but not within the last 6 months
No
Not sure

Please specify which product or type, if you answered 'Yes, currently using' to above.

Have you received any of these hair removal services in the last 30 days?*

Waxing
Sugaring
Threading
Electrolysis / Laser
Depliatory Cream
Shaving
None

If checked, please note last time.

Have you ever received chemical peels, laser services, or microdermabrasion treatments?*

Yes
No

Please tell us when?

Have you had any treatments that include Anti-wrinkle, Fillers, Facial Treads, PRP, Skin needling or Advanced Laser Treatments in the last month?*

Yes
No

Your Health

Have you experienced any of these health conditions in the past or present?

If you checked yes to any of these please provide further information.*

Do you?*

Wear contact lenses
Have a pacemaker
Have metal implants
No, not Applicable

Do you take any of the following dietary / health supplements?*

If other, please list

Any known allergies?*

If other, please list

Have you used or been prescribed any medications (topical or oral) for acne / acne control?*

Yes
No

If yes, please specify what and date last used

Are you a smoker?*

Yes
No
Social

Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)*

Yes
No

Please rate your stress level*

Low
Medium
High

Please let me know if you would like to learn about natural ways to lower stress levels

Female Clients

Are you taking birth control?*

Yes
No
N/A

If yes, what kind

Are you pregnant or trying to become pregnant?*

Yes
No
Recently had a baby and am breastfeeding
N/A

Any menopause / peri menopause issues?*

Yes
No
N/A

If yes, please specify

Are you undergoing any hormone replacement therapy?*

Yes
No

If yes, please specify

Male Clients

What is your current shaving system?*

Razor / Wet shave
Electric
N/A

Do you experience irritation from shaving?*

Yes
No
N/A

Are you undergoing any hormone replacement therapy?*

Yes
No

If yes, please specify

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Our Terms

Post Facial Care/Waxing Instructions: Aerobic exercise and/or vigorous physical activity should be avoided for 48 hours. Direct sunlight exposure is to be avoided immediately following the treatment (including any strong UV light exposure and/or tanning beds). If some sun exposure cannot be avoided first apply a broad spectrum sunscreen of SPF 30. Sunscreen (with a minimum SPF 15) should become part of your daily skin care regimen as skin can potentially become more sensitize to the sun as a result of this treatment. Unless otherwise specified, in the evening following your treatment, cleanse your skin with a mild cleanser and water followed by a non- active moisturizer. Do not apply additional exfoliating ingredients/products the day of your service as over-exfoliation can result in irritation or further sensitivity. Consult your skin care professional before resuming topical treatments. Enzyme peels, DermaFile or DermaDisc treatments, chemical peels or facial waxing can result in skin flushing/redness or slight skin flaking or sensitivity for up to 48-72 hours post treatment. DO NOT peel, pick, rub, or scratch your skin at any time, whatsoever. This can potentially cause damage or compromise your results.*

I have read the post care instructions and agree to adhere to them.

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this skin care professional from liability and assume full responsibility thereof.*

Yes

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