• Client Consultation Form

  • DATE of BIRTH
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  • Have you ever had a facial treatment before?
  • 1. Describe your Skin Type?
  • 2. Do you use Accutane, Retin-A, Renova, Adapalene Hydroxyl Acid or any other Retinol/vitamin A derivative products?
  • 3. Have you experienced Botox, Restylane, or collagen injections?
  • 4. Have you ever had chemicals peels, laser treatments, or microdermabrasion?
  • 5. Do you have any special skin problems or concerns pertaining to your face or body?

  • Current Skin Regimen

  • Have you ever had an allergic reaction to any of the following Check all that apply

  • Lifestyle

  • How many glasses of water do you drink per day?
  • How many caffeinated beverages coffee, tea, soda, etc do you consume per day?
  • Which foods do you consume on a regular basis?
  • Do you exercise regularly?
  • Are you taking oral contraceptives?
  • Are you pregnant or trying to become pregnant?
  • MALE CLIENTS: Do you expereince irritation from shaving?
  • MALE CLIENTS: Do you experience ingrown hairs as a result of hair removal?

  • 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 institution and/or the technician/esthetician/skin care professional from liability and assume full responsibility thereof.

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