The Hair Shed Beauty Consultation Form
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: 00000000000.
Email
example@example.com
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Medical History
Have you experienced any of these health conditions?
*
Hormone Imbalance
High Blood Pressure
Heart Problems
Auto-Immune Disorder
Epilepsy/Seizures
Cancer/Systemic Disease
Diabetes
Arthritis
Asthma
Cold Sores
Other
Do you have any allergies?
*
Aspirin
Fruits
Lidocane
Tree Nuts
Latex
Shellfish
Fragrance/Essential Oils
Dairy
Pollen
Other
Please list any medications you are currently taking
*
If you do not take medication, please enter 'N/A'
Have you ever received botox or fillers? If so, where and when?
*
Have you ever experienced claustrophobia?
*
Yes
No
Your Skin
Do you have any skin concerns?
What would you say your skin type is?
*
Normal (no visible blemishes, fine pores, smooth texture)
Combination (oily and dry patches, oily t-zone, hormonal breakouts)
Acne (cystic or nodules)
Sensitive (reactive to fragrance, often irritated)
Oily (enlarged pores, excessive oil)
Dry (dull, visible lines and wrinkles, feels tight)
What skin care products do you use on a daily basis?
*
Soap
Toner
Mask
Eye Cream
SPF
Cleanser
Serum
Exfoliant (physical or chemical)
Moisturiser
Vitamin A (Retinol)
Other
Do you experience routine breakouts or acne?
*
Yes
No
Have you been diagnosed with eczema, psoriasis or rosacea
*
Yes
No
Have you received any of these facial hair removal services in the last 7 days?
Waxing/Sugaring
Threading
Laser/Electrolysis
Do you currently use Accutane, Retin-A or a prescribed topical cream?
Yes
No
If yes, please confirm which product you use:
If necessary, please submit a photo of specific skin areas
Are you taking birth control?
Yes
No
Are you pregnant or breast-feeding?
Pregnant
Breast-feeding
No
Is there any other information you would like us to know ahead of your appointment?
Signature
Submit
Should be Empty: