Facial and Skincare Client Consultation Form Please fill out this form before your first appointment. Your answers will better help us to meet your needs and ensure that you have a happy and satisfying experience.Name* First Last Appointment Date* MM slash DD slash YYYY Date of Birth* MM slash DD slash YYYY Current Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Best Phone Number*Is the above number* a cell phone a land line Your Email* Emergency Contact Name* First Last Emergency Contact Phone Skin Treatment QuestionsHave you ever had a facial treatment before?* Yes No If yes, when was that? What are your main concerns?* Acne Scars Wrinkles/fine lines Age spots Acne scarring Enlarged pores Deep wrinkles Uneven skin tone Aging Hyperpigmentation Dark eye circles Blackheads/whiteheads Dull/dry skin Dehydrated Sun damage Rosacea Other None of the above What would you like to achieve from your treatment today? Skin Care RoutinePlease check current skin care products you use:* Facial Scrub Cleansing Cream Skin Toner/ Astringent Soap Eye Make-Up Remover Day Cream Exfoliants Eye Cream Night Cream Mask Body Lotion/Cream Body Scrub Other None of the Above What SPF do you use on your face? How often/when? How do you find your skin?* Normal Dry Oily Combination Sensitive/Breakout Acne Very sensitive/Rosacea Mature Do you have any tendencies to any of the following?* Ingrown hair Hyperpigmentation Scarring Bruising Bumps/hives Redness None of the above Are you currently using any products that contain the following ingredients?* Glycolic acid Actic acid Any exfoliating scrubs Any hydroxy acid product Vitamin A derivatives (i.e. retinol) Retin-A Renova None of the above If yes to any of the above please specify the date you received your last treatment. Have you recently received any of the following treatment?* Microdermabrasion Chemical Peel Lash Tint Brow Tint Micro Needling Facial Waxing Laser resurfacing None of the above Do you have any special skin problems or concerns pertaining to your face or body?* Yes No If yes, please specify Have you experienced Botox, Restylane or Collagen injections? If yes, please specify* Yes No If yes, please specify Do you ever experience these conditions on your skin?* Flakiness Tightness Obvious dryness None of the above Your HealthThis information is to ensure we carry out the appropriate treatments for you, taking into consideration any medical conditions which might have treatment contraindications. Are you currently affected by any of the following conditions?*Please indicate any of the following that apply to you: (*Female clients only) Pregnancy* Menopause Heart Condition High blood pressure Rosacea Eczema Asthma Varicose veins Water retention Breast Feeding* Diabetes Epilepsy Psoriasis Dermatitis Skin cancer None of the above Do you have anything you want to share about any conditions listed above?Any other medical conditions?* Yes No If yes, please give some details Are you currently taking any medications?* Yes No If yes, please give some details. Do you suffer from any allergies?* Yes No If yes, please give some details. Do you smoke?* Yes No Are you hearing impaired?* Yes No Do you follow a restricted diet?* Yes No Within the last nine months, have you undergone any surgery?* Yes No Within the last year, have you been under a dermatologist or other physician’s care?* Yes No How would you describe your stress levels from 1- 10 (1=Iow, 10=high):* 1 2 3 4 5 6 7 8 9 10 Do you have anything you want to share about the stress level listed above?How frequently do you exercise:* Everyday 3 times week Once a week Rarely How much plain water do you consume daily?* None 1-2 3-5 6-10 Have you ever had a reaction to any of the following?* Cosmetics Medicine Fragrance Pollen Food Hydroxy acids Animals Sunscreens Other Any other information?EmailThis field is for validation purposes and should be left unchanged. Δ