New Client Consultation Form

New Client Consultation Form
Date*

MonthDayYear
Name*

First NameLast Name
Date of Birth*
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
How did you hear about me?*

Website / Online SearchInstagramFacebookReferralOther
If Referral, please list name
If Other, please let me know
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
Your Skin
What are your skin care goals? *
Your Skin Type*

NormalCombinationDryOilySensitiveAcneicMature/Aging
What are your skin care challenges?*

Wrinkles / Fine LinesHyperpigmentation / Sun DamageAcne / Acne ScarringRedness / RosaceaAgingMelasmaSensitivityIngrown Hair
Please feel free to go into more detail
Have you ever had a facial or skin treatment before?*

YesNo
If Yes, when?
Date and type of facial/treatment
What Skin Care Products do you currently use? (Include name and brand)*

Cleanser / Face WashBar SoapFace Scrub / ExfoliantsTonerSerumsMoisturizerSunscreenEye Product(s)Lip Product(s)
If you are seeking corrective treatments please detail the SPECIFIC products (BRAND & PRODUCT TYPE/NAME) you are currently using so I can best answer any questions on ingredients and help you meet your skin care goals.
Cleanser / Face Wash
Bar Soap
Face Scrub / Exfoliants
Toner
Serums
Moisturizer(s)
Sunscreen
Eye Product(s)
Lip Product(s)
Please list current daytime and night time routine: *
Current AM/PM Routine
Do you/have you used Retin-A, (tretinoin)Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?*

Yes, currently usingYes, but not within the last 30 daysYes, but not within the last 6 monthsNoNot sure
Please specify which product or type, if you answered 'Yes, currently using' to above.
Have you received any of these hair removal services in the last 30 days?*

WaxingSugaringThreadingElectrolysis / LaserDepliatory CreamShavingNone
If checked, please note last time.
Date and Area Treated
Have you ever received chemical peels, laser services, or microdermabrasion treatments? *

Yes, within the last monthYes, within the last 2-3 monthsNo
Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks?*

YesNo
Your Health
Have you experienced any of these health conditions in the past or present?*

Hormone ImbalanceCancer / Systemic DiseaseHigh Blood PressureDiabetesHeart problemArthritisAuto-Immune DisordersAsthmaEpilepsy / Seizure DisorderFever BlistersHerpesFrequent Cold SoresHIV/AIDSLupusDepression/AnxietyHepatitisHeadaches / MigrainesOtherNone
If you checked yes to any of these please provide further information. If not mark N/A*
Do you?*

Wear contact lensesHave a pacemakerHave metal implantsHave body piercingsNo, not Applicable
*
Are you currently on any prescription medication?*
Please list medication or N/A if not applicable
Do you take any of the following dietary / health supplements?

MultivitaminVitamin CVitamin D/D3ZincOmega 3 / Fish OilB Complex / B12GarlicCalciumFolic AcidMelatoninCoenzyme Q10BiotinOther
If other, please list
Any known allergies?*

AspirinTree NutsLatexDairyFruitsVegetablesShellfishIodineFragrances / Essential OilsOtherNone
If Other, please specify
Specify in this section
Have you used or been prescribed any medications (topical or oral) for acne / acne control?*

YesNo
If yes, please specify what and date last used
Are you a smoker? *

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

YesNo
Have you ever experienced claustrophobia? *

YesNo
Please rate your stress level*

LowMediumHigh
Do you have any metal implants*

YesNo
If yes, what kind
Pacemaker, ICD, Medicine Pump, other
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
MALE CLIENTS
What is your current shaving system? *

Razor / Wet shaveElectricN/A
Do you experience irritation from shaving? *

YesNoN/A
Post Facial Care: Aerobic exercise and/or vigorous physical activity should be avoided for 48 hours. Direct sunlight exposure is to be avoided immediately following the treatment (including any strong UV light exposure and/or tanning beds). If some sun exposure cannot be avoided first apply a broad spectrum sunscreen of SPF 30. Sunscreen (with a minimum SPF 15) should become part of your daily skin care regimen as skin can potentially become more sensitize to the sun as a result of this treatment. Unless otherwise specified, in the evening following your treatment, cleanse your skin with a mild cleanser and water followed by a non-active moisturizer. Do not apply additional exfoliating ingredients/products the day of your service as over-exfoliation can result in irritation or further sensitivity. Consult your skin care professional before resuming topical treatments. Enzyme peels, Chemical peels or facial waxing can result in skin flushing/redness or slight skin flaking or sensitivity for up to 48-72 hours post treatment. DO NOT peel, pick, rub, or scratch your skin at any time, whatsoever. This can potentially cause damage or compromise your results.*

I have read the post care instructions and agree to adhere to them.
Reservation & Cancellation Policy for all current and future appointments: a valid credit card is required for all appointments. In the event of cancellations received less than 48 hours prior to appointment, a cancellation fee equal to the reserved service booking will incur. Under 48 hrs = 50% of scheduled service, under 24 hrs or no show = 100% of scheduled service. After 3 missed/rescheduled appointments, full payment for any services will be required in advance.*

I understand the reservation and cancellation policies at Pure Skin Makeup & Skincare Studio and consent to my credit card on file being charged if I fail to give 48 hour notice for appointments scheduled. Pure Skin Makeup and Skincare Studio reserves the right to charge a fee or invoice for missed appointments or late cancellations.
Repeat Late Cancellation - If you cancel with less than a 48-hour notice, more than three times in a year, future reservations will require a full non-refundable pre-payment of any services.*

I understand the Repeat Late Cancellation policy at Pure Skin Makeup & Skincare Studio.
Rescheduling Appointments -Reservations may be rescheduled online at your convenience up to 48 hours prior to the reservation time. The continual rescheduling of reservations, negatively impacts availability for other clients and the profitability of the business. If any appointment has been rescheduled a maximum of three times by the same client within a year, future appointments will require 100% non-refundable prepayment. Additionally, all future appointments must be made within 24 hours and scheduling in advance will not be an option.*

I understand the Rescheduling Appointments policy at Pure Skin Makeup & Skincare Studio.
Late Arrival: Should you be running late, please call or text the studio immediately. If you are 15 minutes late to any appointment your appointment will be cancelled and charged 100%.*

I understand the late arrival policies at Pure Skin Makeup & Skincare Studio and consent to my credit card on file being charged.
Sick Policy : In an effort to maintain a healthy environment, we ask that if you are sick or anyone in your immediate family (which includes a cold, a fever, the flu, etc.) or have the onset of symptoms of an illness that you reschedule your appointment within 48 hours. If you arrive for your appointment with symptoms of an illness, you will be asked to reschedule your appointment and will be charged 100% for your service. Do not come to the studio sick. Abuse of this policy will result in termination of future services.*

I understand the sick policy at Pure Skin Makeup & Skincare Studio and consent to my credit card on file being charged.
PRODUCT SALES/RETURN POLICY - We are committed to providing quality products to our customers. While we hope that you are always satisfied with your purchase, we realize there are times that you may need to return a product. If you need to return your product, please review the following information. Returns must be made within 7 days of your receipt date/purchase for a refund. Merchandise must be in its original, unopened, and unused condition. If products were shipped, we regret that we do not refund original shipping costs with the return. All handmade products, any opened skin care, and makeup are final sale.*

I understand the Product Sales and Return Policy at Pure Skin Makeup & Skincare Studio.
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 skin care professional from liability and assume full responsibility thereof.

Yes
Signature*

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New Client Consultation Form

Your Skin

Your Health