Facial Treatment Consultation Form
Treatment Required
Holistic Facial
Beauty Facial
Facial Reflexology
Zone Face Lift
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How did you hear about me?
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If Other, please let me know
Your Skin
What are your skin care goals?
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What are your skin care challenges?
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Wrinkles / Fine Lines
Hyperpigmentation / Sun Damage
Acne / Acne Scarring
Redness / Rosacea / Sensitivity
Aging
Breakouts
Dry / Flaky
Excess Oil
Other
Please feel free to go into more detail
Have you ever had a facial or skin treatment before?
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Yes
No
If Yes, when?
What Skin Care Products do you currently use?
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Cleanser / Face Wash
Bar Soap
Face Scrub / Exfoliants
Toner
Serums
Moisturizer
Sunscreen
Eye Product(s)
Lip Product(s)
Preferred Brand(s)
Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?
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Yes, currently using
Yes, but not within the last 30 days
Yes, but not within the last 6 months
No
Not sure
Please specify which product or type, if you answered 'Yes, currently using' to above.
Have you received any of these facial services in the last 30 days?
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Waxing
Sugaring
Threading
Electrolysis / Laser
Depliatory Cream
Botox / Dermal Fillers / Facial Injectibles
None
If yes, please confirm last date
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Month
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Day
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Date
Your Health
Have you experienced any of these health conditions in the past or present?
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Hormone Imbalance
Cancer / Systemic Disease
High Blood Pressure
Diabetes
Heart problem
Arthritis
Auto-Immune Disorders
Asthma
Epilepsy / Seizure Disorder
Fever Blisters
Herpes
Frequent Cold Sores
HIV/AIDS
Lupus
Depression/Anxiety
Hepatitis
Headaches / Migraines
Covid-19
Other
None
If you checked yes to any of these please provide further information. If not mark N/A
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Do you?
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Wear contact lenses
Wear hearing aids
No, not Applicable
Do you take any dietary / health supplements?
Yes
No
If yes, please list
Any known allergies (eg: aspirin, latex, nuts, essential oils)?
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Yes
No
If yes, please give details
Have you currently taking any prescription / over the counter medications
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Yes
No
If yes, please give details
Are you a smoker?
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Yes
No
Social
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)
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Yes
No
Do you drink alcohol?
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Yes
No
What is your daily water intake (glasses / litres)
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Have you ever experienced claustrophobia?
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Yes
No
Please rate your stress level
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Low
Medium
High
FEMALE CLIENTS
Are you taking birth control?
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Yes
No
N/A
If yes, what kind
Are you pregnant or trying to become pregnant?
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Yes
No
Recently had a baby and am breastfeeding
N/A
Any menopause issues?
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Yes
No
N/A
If yes, please specify
Are you undergoing any hormone replacement therapy?
Yes
No
If yes, please specify
Is there any other information you would like to make your therapist aware of? If yes, please give details:
After Facial Care Instructions: Avoid direct sunlight exposure immediately after the treatment, including strong UV light and tanning beds. If sun exposure is unavoidable, apply a broad-spectrum sunscreen with at least SPF 30. Facial massage, cupping, and gua sha may cause temporary redness or pinkness, which is a normal and positive outcome indicating increased blood flow from the treatment. Cupping may cause skin markings in areas of stagnation, which typically fade within a few days. If you have any concerns about this, please inform me before the treatment. Unless specified otherwise, in the evening after your treatment, cleanse your skin with a mild cleanser and water, followed by a non-active moisturizer. Avoid using exfoliating ingredients or products on the day of your service to prevent irritation or increased sensitivity. If you experience any concerns after the treatment, please reach out to me.
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I have read the post care instructions and agree to adhere to them.
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