New Client Consultation Form

Treatment Required

Holistic FacialBeauty FacialFacial ReflexologyZone Face Lift

Today's Date*

MonthDayYear

Name*

First NameLast Name

Date of Birth*

Date

Address*

Street Address

Street Address Line 2

City

Country

Phone Number*

E-mail*

example@example.com

Emergency Contact Name

First NameLast Name

Phone Number

Please enter a valid phone number.

How did you hear about me?*

If Other, please let me know

What are your skin care goals? *

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?*

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?*

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?*

If yes, please confirm last date

Date

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 N/A*

Do you?*

Wear contact lensesWear hearing aidsNo, not Applicable

Do you take any dietary / health supplements?

YesNo

If yes, please list

Any known allergies (eg: aspirin, latex, nuts, essential oils)?*

YesNo

If yes, please give details

Have you currently taking any prescription / over the counter medications*

YesNo

If yes, please give details

Are you a smoker? *

YesNoSocial

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

YesNo

Do you drink alcohol?*

YesNo

What is your daily water intake (glasses / litres)*

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

Any menopause issues? *

YesNoN/A

If yes, please specify

Are you undergoing any hormone replacement therapy?

YesNo

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.*

I have read the post care instructions and agree to adhere to them.

Signature*

Facial Treatment Consultation Form

Your Skin

Your Health