Cosmetology Client Consultation Form

Name

First NameLast Name

Age

Email

example@example.com

Phone Number

Please enter a valid phone number.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Occupation

Please select the current health conditions that is present in your body

Do you have any of the following conditions?

Do you have any allergies? If yes, please list them below

Have you undergo any surgical procedure? If yes, please list the name of the procedure and the reason

Are you currently taking any medications? If yes, please list them below including vitamins and supplements:

Date of last menstrual period

Date

Do you have children?

YesNo

Are you wearing contact lenses?

YesNo

Are you engaged in any sport? If yes, please share what sports are you currently taking:

How do you take care of your face?

How do you take care of your skin?

What are the cosmetic products you're currently using?*

When is the last time you had a professional cosmetic care?

Date

How often do you go to a beauty salon?

Are you preparing for a special occasion?

YesNo

What type of event this cosmetic care is for?

When is the event?

Date

What time is the event?

Hour Minutes

AM/PM Option

Would you like a trial service?

YesNo

What date can we do the trial service?

Date

Do you have any special instructions?

Would you like to receive promotions and offers via email?

YesNo

How did you hear about us?

I confirmed that all information I entered in this form is accurate and true.

Client's Signature

Date Signed

Date