New Client Consultation Form

Date*

MonthDayYear

Name*

First NameLast Name

Date of Birth*

Address*

Street Address

Street Address Line 2

BarangayCity

ProvinceCountry

Mobile Number*

Area CodePhone Number

E-mail*

example@example.com

Occupation *

How did you hear about us?*

If Referral, please list name

If Other, please let us know

Preferred Date*

Preferred Branch*

West Avenue, QCVisayas Avenue, QC3F New Wing, Robinsons Place Magnolia

What are your skin care goals?*

Acne FreeWrinkle FreeBrighterYounger Looking

What are your skin care challenges?*

Please feel free to go into more detail

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

YesNo

If Yes, when?

What Skin Care Products do you currently use?*

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

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?*

If checked, please note last time.

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

Yes, within the last monthYes, within the last 2-3 monthsNo

Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks?*

YesNo

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. If not mark, NA*

Do you?*

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

If other, please list

Any known allergies?*

If Other, please specify

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

YesNo

If yes, please specify what and date last used

Are you a smoker? *

YesNoSocial

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

YesNo

Have you ever experienced claustrophobia? *

YesNo

Please rate your stress level*

LowMediumHigh

FEMALE CLIENTS

Are you taking birth control? *

YesNoN/A

If yes, what kind

Are you pregnant or trying to become pregnant?*

YesNoRecently had a baby and am breastfeedingN/A

When was your last period? *

Any menopause issues? *

YesNoN/A

If yes, please specify

Are you undergoing any hormone replacement therapy?

YesNo

If yes, please specify

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.

Online Consultation Reservation and Cancellation Policy: 1. A Non-Refundable Online Consultation Fee of P500 is required, but deductible upon your payment at the clinic during actual servicing.  2. Cancellations or no show until the day of the appointment may be rebooked upon advice of the client, however will be subject again to Patient Evaluation and Triaging and schedule availability.  3. In the event of a second cancellation or no show, only 50% of Online Consultation Fee will be deductible.   4. In the event of a third cancellation or no show, the full amount is waived.*

I understand the reservation and cancellation policies at AesthetiQ Wellness and Spa.

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

Signature*

New Client Consultation Form

Online Consultation Schedule

Your Skin

Your Health