New Client Consultation

Date

MonthDayYear

Name

First NameLast Name

Date of Birth

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Heritage/Ethnicity

Phone Number

Area CodePhone Number

E-mail

How did you hear about me?

If Referral, please list name

Please list all skin care you are currently using. Please be specific when listing products (include brand & product type/name).

Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?

Please list all face makeup products you are currently using. Please include product brand and product type/name.

Have you ever received chemical peels, laser services, or microdermabrasion treatments?

Have you received any of these facial hair removal services in the last 30 days?

If checked, please note last time.

Have you received any Botox in the last two weeks?

Have you received any fillers in the last 30 days?

Have you experienced any of these health conditions in the past or present?

Do you?

Please list ALL prescribed, over the counter, including vitamins, and recreational drugs (past & present)

If other, please list

Please list all known allergies

Please list any skin conditions you would like me to know about

If acne is your primary concern, at what age did your acne begin?

Are you a chronic skin 'picker?'

Do you smoke?

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

Please rate your stress level

Are you taking birth control?

If yes, what kind

Are you pregnant or trying to become pregnant?

What results would you like to achieve with your skin?

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 and chemical peels 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.

Reservation & Cancellation Policy for all current and future appointments: a valid credit card is required for all appointments. Please do not forget to confirm your appointment when you receive your reminder from Vagaro. In the event of cancellations received less than 24 hours prior to appointment, a cancellation fee equal to the reserved service will incur. No Shows will be charged 100% *

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.

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