New Client Consultation Form

New Client Consultation Form

Welcome to Skin Harmony. Please compete this form as thoroughly as possible.
Date *

Month Day Year
Name *

First Last
*
Type a question
Address *

Street

Street Address Line 2

City State

Zip Country
Mobile Number *

Area Code Phone Number
E-mail *
How did you hear about me? *

Instagram Facebook Referral Other
If Referral, please let me know who I can thank!
Your Skin
Which concerns apply to your skin? *

Wrinkles / Fine Lines Loss of Firmness Discoloration / Sun Damage Acne / Acne Scarring Excessive Oiliness Redness / Rosacea Sensitivity Dryness Rough Skin / Texture Unwanted Hair
If "other", please explain.
What is your primary reason for coming to see me?

Just need some "me" time Some aspects of my skin really bother me Both
Have you ever had a facial or skin treatment before? *

Yes No
If "yes" to above, please provide date.

Month Day Year
Date
What Skin Care Products do you currently use? *

Cleanser / Face Wash Bar Soap Face Scrub / Exfoliants Toner Serums Moisturizer Sunscreen Eye Product(s) Lip Product(s)
If you checked any of the above, please enter the brand name(s) below.
This is not required but will help me to properly address any skin care concerns.
Product name(s)
Cleanser/Face Wash
Bar Soap
Face Scrub / Exfoliants
Toner
Serums
Moisturizer(s)
Sunscreen
Eye Product(s)
Lip Product(s)
Do/have you used any products containing Retin-A (oral or topical), Retinol, or other Vitamin A derivitives, Tretinoin, Glycolic Acid, Lactic Acid, Mandelic Acid? *

Yes, currently using Yes, but not within the last 30 days Yes, but not within the last 6 months No Not sure
If you answered "Yes" to any of the above, please provide details.
Have you received any of these hair removal services in the last 30 days? *

Waxing Sugaring Threading Electrolysis / Laser Depliatory Cream None
If you checked any of the above, please specify.
Have you ever received chemical peels, laser services, microdermabrasion, microneedling, dermaplaning, or any aggressive skin treatments? *

Yes, within the last month Yes, within the last 2-3 months No
If you checked "Yes" to any of the above, please explain.
Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks? *

Yes No
Your Health
Are you currently or have you ever experienced any of these health conditions? *

Hormone Imbalance Cancer / Systemic Disease 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 Other None
If you checked ANY of the conditions above, please provide further information. This information is completely confidential and for your protection.
Do you? *

Wear contact lenses Have a pacemaker Have metal implants Have body piercings No
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 Dairy Fruits Vegetables Shellfish Iodine Fragrances / Essential Oils Other None
If you marked yes to any of the above, please provide details.
Have you used or been prescribed any medications (topical or oral) for acne / acne control, such as Accutane, Adapalene, Differen ? *

Yes No
If yes, please specify what and date last used
Are you a cigarette/vape smoker? *

Yes No
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks) *

Yes No
Do you suffer from claustrophobia? *

Yes No
Please rate your average stress level *

Low Medium High
FEMALE CLIENTS
Are you taking birth control or have an IUD ? *

Yes No
If yes, please specify
Are you pregnant or trying to become pregnant? *

Yes No Not sure Recently had a baby and am breastfeeding
Are you menopausal? *

Yes No Not sure
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
Release of Liability
I understand and acknowledge there are risks involved with the treatment of facials, peels, microdermabrasion, microcurrent, electrical skin treatments, and waxing. I understand any false or misleading information I have given may lead to undesired results and complications. I further understand my failure to follow post care instructions may also lead to undesired results, complications, or effects. I understand that an Esthetician does not diagnose illness, disease, or any other physical or mental conditions. To the maximum extent allowed by law, I agree to waive and release any and all present and future claims, suits or related causes of action against Skin Harmony, for negligence, injury, loss, costs or other injuries or damages to me as a results of any procedure. *

I understand, have read and completed this questionnaire truthfully.
Cancellations/Late Arrivals/No Shows
If you need to cancel, 24 hours notice is much appreciated. I understand that a change is sometimes necessary; however, my time is valuable. I work my schedule around your appointment time. If this policy is not adhered to more than twice, I reserve the right to require a $25 deposit when booking your next appointment. Please keep in mind: arriving late for your appointment may shorten your treatment time. If you decide to go forward with the service, although shortened, there will not be a cost discount. If you are more than 15 minutes late, we might need to reschedule. Thank you very much for your understanding and I look forward to serving you. *

I have read the cancellation instructions and agree to adhere to them.
Signature and Date *

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New Client Consultation Form

Your Skin

Your Health