Core Skin Studio Consultation Form
While this consultation form is a little lengthly (apologies in advanced) - it is required to make sure we can review and address all concerns, medications, current skincare/lifestyle, allergies, and or any other contraindications prior to your appointment.
Basic Information
Legal Name
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First Name
Last Name
Preferred Name (if different than above)
First Name
Last Name
Birthday
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-
Month
-
Day
Year
Date
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Email (no icky spam emails, I promise!)
example@example.com
How did you hear about us
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Please Select
Recommendation/referral
Social Media (Instagram/Facebook)
Google Search
Face Reality Locator
Other
Name of referral (to track referral bonus!)
Occupation
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Ethnicity (multiple selection, if applicable)
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Asian
East Asian (Chinese, Korean, Japanese)
South Asian (Indian, Pakistani, Bangladeshi)
Southeast Asian (Filipino, Vietnamese, Thai, Indonesian)
Black or African American
Caucasian / White
Hawaiian Native or Other Pacific Islander
Hispanic or Latino
Indigenous / Native American / Alaska Native
Middle Eastern or North African
Other
Skin History + Concerns
What are your current skin concerns? (check all that apply)
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Pigmentation/freckles
Dryness
Oily
Texture
Acne
Blackheads
Pore Size
Acne scarring
Aging/fine lines
Wrinkles
Eye Area
Firmness
Neck Area
Chest/Décolleté
Capillaries/broken blood vessels
Premature Aging
Redness
Rosacea
Sensitivity
Other
How long have you had these concerns?
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What are your main skin goals?
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Have you had a reaction to a skincare product or treatment before?
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Yes
No
If you answered yes to the previous question, please explain.
Have you had a facial or skin treatment before?
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Yes
No
When was your last treatment?
What was the name of the treatment?
Have you had a chemical peel or laser treatment in the last 2 years?
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Yes
No
Unsure
Have you had plastic surgery, filler, botox, POD threads, or any other cosmetic procedures?
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Yes
No
If yes, please give short description as to each procedure you've had above and when and/or how long you been receiving.
Name or brand of peel(s)?
Current Skincare Routine
Please list current skincare you use at home (AM/PM/weekly)
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Please list all current skincare you use at home (AM/PM/Weekly/Monthly)
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Are you currently using an prescription skincare? (tretinoin, hydroquinone, topical antibiotics, topical steroid creams)
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Yes
No
If you answered yes to the question above, please explain
Are you consistent with your routine?
Always (every day without fail)
Mostly (might miss here and there, but rare)
Sorta (I do more my AM or PM routine over the other)
Not Consistent (I'm lucky if I remember or try)
Does your current routine deliver the results you desire?
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Yes
No
Not sure
Do you exfoliate? (Physically or chemically) examples: scrubs, aha, bha, retinols, benzoyl peroxide
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Yes
No
If yes, what type of exfoliant do you use?
How often do you exfoliate
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Please Select
Never
Once or twice monthly
1-2 times a week
3-5 times a week
Everyday
Do you use sunscreen daily?
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Yes
No
Are you currently using any Retinol, AHA, BHA or any peeling agent?
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Yes
No
Other
If yes, what products?
How long have you been using this/these product(s)?
If yes, please describe.
Internal Health Snapshot + Lifestyle
(This section helps identify possible factors influencing your skin)
Which of the following best describes your typical eating style?
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Omnivore (eat both animal and plant-based foods)
Carnivore (primarily or exclusively animal-based foods)
Pescatarian (eat fish but no other meat)
Vegetarian (no meat, may include dairy/eggs)
Vegan (no animal products)
Plant-based (mostly plants, not strictly vegetarian or vegan)
Dairy-free
Gluten-free
Other
Which of the following best describes your typical eating style?
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Please Select
Omnivore (eat both animal and plant-based foods)
Carnivore (primarily or exclusively animal-based foods)
Pescatarian (eat fish but no other meat)
Vegetarian (no meat, may include dairy/eggs)
Vegan (no animal products)
Plant-based (mostly plants, not strictly vegetarian or vegan)
Dairy-free
Gluten-free
Other (please describe)
Do you have any food allergies outside of gluten or dairy?
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Please list any vitamins, dietary or herbal supplements you take/consume daily (non-prescription) If you do not take any, please list N/A.
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Please list any vitamins and dietary or herbal supplements you consume. (non-prescription)
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Do you smoke? (cigarettes, vapes, cannabis)
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Cigarettes
Vapes
Cannabis
I do not smoke
Do you drink alcohol? (can be mixed drinks, wine, or canned drinks such as beer, seltzers, etc.)
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1-2 drinks per week
3-5 drinks per week
5+ drinks per week
Rarely drink (maybe 1-2x per month)
Never drink (maybe a few times per year)
Does your diet consist of many added sugars? (Over 50g daily)
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Yes
No
Only cravings
Do you consume any type of supplementary protein such as protein bars, drinks, or powders? If yes, please explain.
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How much water do you consume per day? (in ounces or cups)
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How much coffee/tea/energy drinks (caffeine) do you consume per day? (in ounces or cups)
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Rate your stress level (0-10; 0=no stress, 10=chronic stress)
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How often do you exercise or move your body?
Daily (every day)
Most days (5-6 days a week)
Some days (3-4 days a week)
Minimal (1-2 days a week)
Hardly (under 1 day a week)
How many hours of sleep do you get a night? (on average)
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9+ hours
7-8 hours
5-6 hours
Under 4 hours
How often do you have a bowel movement? (helps with gut-skin connection)
Daily (I poop at least 1x per day most days)
5-6 bowel movements a week
3-4 bowel movements a week
Under 2 bowel movements a week
Medical Diagnoses + Health Conditions
Please make sure you list any and all past/present diagnoses
Digestive & Gut Health: check all that apply
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IBS (Irritable Bowel Syndrome)
IBD (Crohn’s, Ulcerative Colitis)
SIBO (Small Intestinal Bacterial Overgrowth)
Food allergies or intolerances
GERD / Acid reflux
Celiac disease
Malabsorption Syndrome
None
Other
Metabolic & Autoimmune: check all that apply
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Insulin resistance / Pre-diabetes
Type 1 or Type 2 Diabetes
Adrenal fatigue / HPA axis dysfunction
Lupus
Rheumatoid arthritis
None
Other
Hormonal + Reproductive Health: check all that apply
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PCOS (Polycystic Ovary Syndrome)
Endometriosis
Irregular or absent menstrual cycles
Hormonal imbalances (estrogen dominance, low progesterone, high androgens)
Thyroid disorder (hypothyroidism, hyperthyroidism, graves' disease, hasimotos)
Menopause or perimenopause
None
Other
Are you currently on any form of birth control?
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Yes
No
N/A
Are you or could you be pregnant and/or nursing?
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Yes
No
N/A
Are you currently trying to get pregnant or undergoing infertility treatment?
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Yes
No
N/A
Have you ever had your hormones tested?
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Yes
No
Cardiovascular, Blood & Oncology History: check all that apply
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History of blood clots or clotting disorder
Factor 5
History of stroke or heart condition
Anemia or blood disorders
Current or past cancer diagnosis
History of tumors or cysts (benign or malignant)
Currently undergoing treatment (chemo, radiation, immunotherapy)
High blood pressure
Low blood pressure
None
Other
Skin-Related Conditions: check all that apply
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Chronic or cystic acne
Eczema (atopic dermatitis)
Contact dermatitis (reaction to products, metals, synthetic fragrances)
Seborrheic dermatitis (common on scalp, brows, sides of nose)
Perioral dermatitis (around mouth or nose)
Rosacea
Psoriasis
Hyperpigmentation / Post-Inflammatory Hyperpigmentation (PIH)
Hypopigmentation or vitiligo
Keratosis pilaris ("chicken skin" on arms/thighs)
Keloid or hypertrophic scarring tendency
Frequent skin infections (staph, fungal, cold sore outbreaks)
None
Other
Do you have a tendency to keloid scar?
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Yes
No
Mental Health & Nervous System: check all that apply
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Anxiety
Depression
Attention Deficit Hyperactivity Disorder (ADHD)
Sleep disorders / chronic fatigue
None
Other
Have you in the past or present had any of the following?
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Epilepsy
Diabetes
Thyroid Problems
Heart Problems
Cancer
Hysterectomy
Hormonal Imbalance
Depression
High or Low Blood Pressure
None
Other
Do you suffer from claustrophobia?
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Yes
No
Have you been under a physicians care during the past 3 years? (Other than physical/routine check ups)
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Yes
No
If yes, please describe.
Allergies
Please list any known or suspected allergies or sensitivities — topical, environmental, or internal (including foods, medications, skincare, etc.).
Common allergies to check if applicable:
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Latex
Lidocaine or numbing agents
Adhesives (bandages, tapes)
Synthetic fragrances
Essential oils
Nickel or metals
Benzoyl peroxide
Salicylic acid
Retinoids / retinol
Sulfa drugs or sulfonamides
Antibiotics (penicillin, erythromycin)
Food (dairy, gluten, eggs, shellfish, nuts)
None
Other
If needed, please explain allergies in more detail
Do you have a history of anaphylaxis? (severe allergic reaction)
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Yes
No
Other
If you selected "Other" above, please list any other medical conditions or history
Medications
Please list all medications you are currently taking (prescription or over-the-counter, including any hormonal therapy)
Are you currently taking any medications?
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Yes
No
Medication List (if you answered yes above, please list all current medications)
Are you currently taking accutane or roaccutane?
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Yes
No
Have you taken accutane or roaccutane in the past?
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Yes
No
If yes, how many rounds and when?
Name of prescription medications and how long you've been on them (Put N/A if not applicable)
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If yes, what form are you currently using? For how long?
Consents + Signature
Medical Disclaimer & Service Eligibility: I understand that Mikayla (Core Skin Studio) is not a medical professional. Core Skin Studio has the right to deny service or ask for written approval from a doctor if there is a significant risk involved due to health complications, pregnancy, allergies, conditions, etc.
*
I have read and understand the above, and I consent to receive services under these terms.
Treatment Sensation & Reaction Acknowledgment: Treatments provided by Core Skin Studio are results-focused and may cause temporary sensations such as tingling, itching, or warmth, as well as slight erythema (redness). I understand that these reactions are normal and typically subside within 20-35 minutes after my appointment. I recognize that individual responses may vary and that any prolonged or unusual reactions should be reported to Core Skin Studio as soon as possible.
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I have read and understand the above, and I consent to treatment with this knowledge.
Treatment Photo Policy: At Core Skin Studio, we document each treatment with photos to monitor progress and maintain accurate client records. These photos are taken before and/or after each session and are required for legal, clinical, and goal-tracking purposes.
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I have read and understand to having photos taken for documentation purposes at each appointment. These will be kept confidential and stored securely in my client file.
Optional Social Media / Marketing Consent: Occasionally I share real client results on my website and social media to showcase the effectiveness of treatments and educate others on skin health. Your privacy is a top priority and I will never tag you or share your name. Photos may include full face, partial face, or close-up skin areas (cheek, jawline, forehead).
I give permission for Core Skin Studio to use my treatment photos for marketing purposes, including but not limited to social media, website, and educational content.
I do NOT give permission to use my treatment photos for marketing purposes.
I agree to not bring any guests (including children) without prior approval from Core Skin Studio
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Yes
Client Responsibility & Disclosure Agreement: I have, to the best of my knowledge and ability, disclosed all known allergies, medications, medical conditions, and diagnoses at the time of filling out this form. I understand that withholding or failing to disclose relevant information may increase the risk of adverse reactions. Core Skin Studio is not liable for any complications, reactions, or issues arising from undisclosed or inaccurate information and is released from any legal responsibility in such cases.
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I have read and agree to the above terms regarding my responsibility to disclose accurate health information.
Client Typed Signature (Full Legal Name)
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THANK YOU!!
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