New Client Consultation Form

1
Name* This field is required.Please complete
First Name
Last Name
2
Date of Birth* This field is required.Please complete
Date
Day
Month
Year
3
Address* This field is required.Please complete
Property Number and Street
Street Address 2
City
Please Select
Please Select
County Durham
Darlington
Hartlepool
Middlesbrough
North Yorkshire
Redcar and Cleveland
Stockton-on-Tees
Tyne and Wear
Other
County
Post Code
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United States
Afghanistan
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The Bahamas
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Belize
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Bosnia and Herzegovina
Botswana
Brazil
Brunei
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Canada
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Chad
Chile
China
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Laos
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Liberia
Libya
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Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
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Paraguay
Peru
Philippines
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Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
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Saint Barthelemy
Saint Helena
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Samoa
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Saudi Arabia
Senegal
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Slovenia
Solomon Islands
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eSwatini
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United Arab Emirates
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Uzbekistan
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Vatican City
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British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Mobile Number* This field is required.Please complete
Area Code (if applicable)
Phone Number
5
E-mail* This field is required.Please complete
example@example.com
Email Verified
The verification code has been sent to some@email.com
Please check your mailbox and paste the code below to complete verification
••••
Didn't receive verification code? orReceiving the email may take a few minutes, thank you for your patience!
6
How did you hear about us?* This field is required.
Website / Online Search
Facebook
Instagram
Referral
Others
7
If Referral, please list name
8
If Other, please let us know
9
What are your skin care goals?* This field is required.
Younger Looking
Wrinkle Free
Brighter
Acne Free
10
What are your skin care challenges?* This field is required.
Wrinkles / Fine Lines
Sun Damage
Acne / Acne Scarring
Redness / Rosacea
Aging
Dehydration
Sensitivity
Other
11
Have you ever had a facial or skin treatment before?* This field is required.
Yes
No
12
What Skin Care Products do you currently use?* This field is required.
Cleanser / Face Wash
Bar Soap
Face Scrub / Exfoliants
Toner
Serums
Moisturizer
Sunscreen
Eye Product(s)
Lip Product(s)
13
Have you used any form of Retinol or Vit-A treatments?* This field is required.
Yes, currently using
Yes, but not within the last 30 days
Yes, but not within the last 6 months
No
Not sure
14
Have you received any of these hair removal services in the last 30 days?* This field is required.Please tick appropriately
Waxing
Threading
Electrolysis / Laser
Depliatory Cream
Shaving
None
15
Have you ever received chemical peels, laser services or microdermabrasion treatments?* This field is required.Please tick appropriately
Yes, within the last month
Yes, within the last 2-3 months
No
16
Have you received any type of injectionables (Botox and/or dermal fillers), in the last two weeks?* This field is required.Please tick appropriately
Yes
No
17
Have you experienced any of these health conditions in the past or present?* This field is required.
Shortness of Breath
Cancer / Systemic Disease
High Blood Pressure
Low Blood Pressure
Diabetes
Heart problem or Chest Pain
Arthritis or Pain during Movement
Auto-Immune Disorders
Asthma
Epilepsy / Seizure Disorder
Herpes
Frequent Cold Sores
HIV/AIDS
Lupus
Depression/Anxiety
Hepatitis
Headaches / Migraines
Eczema / Psoriasis
None
Other
18
If you checked Other please provide further information
19
Do you?* This field is required.Please tick appropriately
Wear contact lenses
Have a pacemaker
Have metal implants
Have body piercings
Wear hearing aids
Not Applicable
20
Any known allergies?* This field is required.Please tick appropriately
Aspirin
Nuts
Latex
Dairy
Fruits
Vegetables
Shellfish
Iodine
Fragrances / Essential Oils
Other
None
21
If Other, please specifyPlease give further details
22
Have you used or been prescribed any medications (topical or oral) for acne / acne control?Please tick if appropriate
Yes
No
23
Are you a smoker?
Yes
No
Ex-smoker
24
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)
Yes
No
25
Have you ever experienced claustrophobia?
Yes
No
26
Employment Status
Full-time
Part-time
Volunteer
Retired
Full-time mother/carer
27
Please rate your stress level* This field is required.Please tick appropriately
Low
Medium
High
28
Ambient MusicAll treatments are accompanied by soothing music. Would you like this to be played during your therapy?
YESNO
29
Massage TherapiesPlease use your touch pad or touch screen to draw on the images below. Use BLACK to identify those areas you feel require additional attention. Use RED if you wish any area to be avoided. Click on the black colour square below to change colours.
30
Are you taking birth control? * This field is required.
Yes
No
N/A
31
Are you pregnant or trying to become pregnant?* This field is required.
Yes
No
Recently had a baby and am breastfeeding
N/A
32
Any menopause issues? Please tick appropriately
Yes
No
N/A
33
Are you undergoing any hormone replacement therapy?
Yes
No
34
Keeping in Touch* This field is required.Would you like to receive information regarding the following - please select as appropriate
Appointment Reminders
New Treatments and Therapies
Special Offers and Discounts
New Products
35
Skincare* This field is required.Post Facial Care/Waxing Instructions: 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 sensitive to the sun as a result of these treatments. 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 treatment 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.
36
Cancellation Policy* This field is required.
I understand the reservation and cancellation policies at Ultra Chique Clinique.
37
Consent* This field is required.I confirm that all the information given in this questionnaire has been done so to the best of my knowledge. I agree that these details constitute full disclosure and I take full responsibility for my wellbeing throughout the duration of my time at Ultra Chique Clinique. I agree to provide up-to-date information and relevant details to all staff/therapists in order to ensure a happy and healthy experience.
Yes
38
Signature* This field is required.Please sign using your touch pad or by drawing on your touch screen - thank you
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