Skin Care Consultation Form

CONFIDENTIAL SKIN CARE TREATMENT CONSULTATION AND 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	Country

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? *

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
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 *
Signature *
Should be Empty:

Now create your own JotForm - It's free! Create your own JotForm

CONFIDENTIAL SKIN CARE TREATMENT CONSULTATION AND CONSENT FORM

YOUR SKIN

CURRENT SKIN CARE REGIMEN

YOUR HEALTH

FEMALE CLIENTS

MALE CLIENTS