Client Consultation

Relax Your Body ~ Rejuvenate Your Mind ~ Renew Your Spirit.

Date *

Name *

Date of Birth *

Address *

Cell Phone: *

Email *

Referred by:

What would you like to achieve from your treatment today?

Your Skin Care

1. Have you ever had a facial treatment before?

No
Yes

2. Which of the following best describes your skin type? (Please circle one type number) *

Creamy complexion - Always burns easily, never tans
Light Complexion - Always burns, tans slightly
Light/Matte Complexion - Burns moderately, tans gradually
Matte Complexion - Seldom burns, always tans well
Brown Complexion - Rarely burns, deep tan
Black Complexion - Never burns, deeply pigmented

3. Do you have any special skin problems or concerns pertaining to your face or body? *

Yes
No

4. Have you ever had chemical peels, laser or microdermabrasion? *

Yes
No

5. Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products? *

Yes
No

6. Have you used any of these products in the last 3 months?

Yes
No

7. Have you used an acne medication?

Yes
No

When?

Which drug?

8. What skin care products are you currently using? (List brand where known)

10. Have you ever had an allergic reaction to any of the following? *

No
Yes

Please Explain *

11. Have you had any recent tanning bed or sun exposure that changed the color of your skin?

No
Yes

12. Have you experienced Botox, Restylane or Collagen injections? *

No
Yes

May I call you at your home, work or cell phone number to confirm future appointments? *

Yes
No

May I contact you via mail/email about future promotions and news? *

Yes
No

Checkboxes *

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 institution and/or skin care professional from liability and assume full responsibility thereof.

Client Signature

Date *

Numbers

Client Consultation

Your Skin Care

All Services are By Appointment Only

Relax and Unwind At Our All Natural Boutique Spa!

Quick Links

Business Hours

Contact Info