FACIAL TREATMENT QUESTIONNAIRE + CONSENT FORM
DATE
*
/
Month
/
Day
Year
Date Picker Icon
NAME
*
First Name
Last Name
DATE OF BIRTH
ADDRESS
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
PHONE NUMBER
*
-
Area Code
Phone Number
E-MAIL
*
DO I HAVE PERMISSION TO TEXT OR EMAIL SPECIALS?
*
TEXT
BOTH
EMAIL
NEITHER
HOW DID YOU HEAR ABOUT ME?
*
WEBSITE/ INTERNET SEARCH
YELP
FACEBOOK
INSTAGRAM
REFERRAL
OTHER
IF REFERRAL, PLEASE LIST NAME
IF OTHER, PLEASE LET ME KNOW
YOUR SKIN
WHAT ARE YOUR SKINCARE GOALS?
*
WHAT ARE YOUR SKINCARE CHALLENGES?
*
WRINKLES/ FINE LINES
HYPERPIGMENTATION/ SUN DAMAGE
ACNE/ ACNE SCARRING
REDNESS/ ROSACEA
AGING
SENSITIVITY
OTHER
PLEASE FEEL FREE TO GO INTO MORE DETAIL
HAVE YOU EVER HAD A FACIAL OR SKIN TREATMENT BEFORE?
*
YES
NO
IF YES, WHEN?
WHAT SKINCARE PRODUCTS DO YOU CURRENTLY USE?
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CLEANSER/ FACE SOAP
BAR SOAP
FACE SCRUBS/ EXFOLIANTS
TONER
SERUMS
MOISTURIZER
SUNCREEN
EYE PRODUCT(S)
LIP PRODUCT(S)
CURRENT SKIN CARE REGIMEN
Please list 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. Please type "NONE" if you currently do not use that type of product.
CLEANSER/ FACE SOAP
*
BAR SOAP
*
FACE SCRUBS/ EXFOLIANTS
*
TONER
*
SERUMS
*
MOISTURIZER
*
SUNSCREEN
*
EYE PRODUCT(S)
*
LIP PRODUCT(S)
*
DO YOU CURRENTLY USE A CLARISONIC OR OTHER CLEANSING BRUSH?
*
YES
NO
IF YES, WHICH BRAND/TYPE?
DO YOU/ HAVE YOU USED RETIN-A, RENOVA, ADEPALENE, ACCUTANE, DIFFEREN, GLYCOLIC ACID, LACTIC ACID, MANDELIC ACID, RETINOL, OR OTHER VITAMIN A DERIVATIVES?
*
YES, CURRENTLY USING
YES, BUT NOT WITHIN THE LAST 30 DAYS
YES, BUT NOT WITHIN THE LAST 6 MONTHS
NO
NOT SURE
Other
IF CHECKED YES, PLEASE INDICATE WHICH PRODUCT(S).
Have you received any of these hair removal services in the last 30 days?
*
WAXING
SUGARING
THREADING
ELECTROLYSIS
DEPILATORY CREAM
SHAVING
NONE
IF CHECKED, PLEASE NOTE LAST TIME.
HAVE YOU EVER RECEIVED CHEMICAL PEELS, LASER SEVICES, OR MICRO DERMABRASION TREATMENTS?
*
YES, WITHIN THE LAST MONTH
YES, WITHIN THE LAST 2-3 MONTHS
NO
HAVE YOU RECEIVES ANY BOTOX, JUVEDERM, OR OTHER DERMAL FILLERS IN THE LAST TWO WEEKS?
*
YES
NO
IF YES, WHICH TREATMENT AND WHEN?
YOUR HEALTH
HAVE YOU EXPERIENCED ANY OF THESE HEALTH CONDITIONS IN THE PAST OR PRESENT?
*
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
NONE OF THE ABOVE
IF CHECKED YES TO ANY OF THESE PLEASE PROVIDE FURTHER INFORMATION.
DO YOU?
*
WEAR CONTACT LENSES
HAVE A PACEMAKER
HAVE METAL IMPLANTS
HAVE BODY PIERCINGS
NONE OF THE ABOVE
IF CHECKED, PLEASE SPECIFY.
DO YOU TAKE ANY OF THE FOLLOWING DIETARY/ HEALTH SUPPLEMENTS?
MULTIVITAMIN
VITAMIN C
VITAMIN D/ D3
ZINC
OMEGA 3/ FISH OIL
B COMPLEX/ B12
GARLIC
CALCIUM
FOLIC ACID
MELATONIN
COENZYME Q10
BIOTIN
OTHER
IF OTHER, PLEASE LIST.
ANY KNOWN ALLERGIES?
*
ASPIRIN
TREE NUTS
LATEX
DAIRY
FRUITS
VEGETABLES
SHELLFISH
IODINE
FRAGRANCES/ ESSENTIAL OILS
OTHER
NONE
IF OTHER, PLEASE SPECIFY.
HAVE YOU USED OR BEEN PRESCRIBED ANY MEDICATIONS (TOPICAL OR ORAL) FOR ACNE/ ACNE CONTROL?
*
YES
NO
IF YES, PLEASE SPECIFY.
ARE YOU A SMOKER?
*
YES
NO
SOCIAL
DO YOU DRINK MORE THAN 4 CAFFEINATED BEVERAGES A DAY? (TEA, COFFEE, SODA, ENERGY DRINKS)
*
YES
NO
HAVE YOU EVER EXPERIENCED CLAUSTROPHOBIA?
*
YES
NO
PLEASE RATE YOUR STRESS LEVEL.
*
LOW
MEDIUM
HIGH
FEMALE CLIENTS
ARE YOU TAKING BIRTH CONTROL?
*
YES
NO
N/A
IF YES, WHAT KIND?
ARE YOU PREGNANT OR TRYING TO BECOME PREGNANT?
*
YES
NO
RECENTLY HAD A BABY AND AM BREASTFEEDING
N/A
ANY MENOPAUSAL ISSUES?
*
YES
NO
N/A
IF YES, PLEASE SPECIFY.
ARE YOU UNDERGOING ANY HORMONE REPLACEMENT THERAPY?
YES
NO
IF YES, PLEASE SPECIFY.
MALE CLIENTS
WHAT IS YOUR CURRENT SHAVING SYSTEM?
*
RAZOR/ WET SHAVE
ELECTRIC
N/A
DO YOU EXPERIENCE IRRITATION FROM SHAVING?
*
YES
NO
N/A
Post Facial Care 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 understand all of the above mentioned reactions. I also understand if I change my skin care routine or medications I must inform Laura Stockwell Licensed Aesthetician PRIOR to starting any service in the future. I will notify my Aesthetician immediately with any questions or concerns in regards to my facial treatment service.
*
I have read the post care instructions and agree to adhere to them.
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
CLIENT NAME
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Signature
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SUBMIT
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