Skin Care Consultation Form

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?*

Do you take any of the following dietary / health supplements?

If other, please list

Any known allergies?*

If Other, please specify

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

Please let us know if you would like to learn about natural ways to lower stress levels

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

Please upload photos or files

Browse Files

Detailed information allow us to schedule the right specialist

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 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, DermaFile or DermaDisc treatments, 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.

Signature*

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