Consultation Please enable JavaScript in your browser to complete this form.Date *Name *Date of Birth *Address *Cell Phone: *Email *Employer: *Occupation: *Does your job require that you work outdoors? *NoYesReferred by: What would you like to achieve from your treatment today?Your Skin Care1. Have you ever had a facial treatment before?NoYes2. Have you ever had a body spa treatment before?NoYesWhen?Massage: YesNoSalt glow:YesNoSeaweed wrap: YesNoMoor mud: YesNoBody scrub: YesNoOther 3. Which of the following best describes your skin type? (Please circle one type number) *Creamy complexion - Always burns easily, never tansLight Complexion - Always burns, tans slightlyLight/Matte Complexion - Burns moderately, tans graduallyMatte Complexion - Seldom burns, always tans wellBrown Complexion - Rarely burns, deep tanBlack Complexion - Never burns, deeply pigmented 4. Do you have any special skin problems or concerns pertaining to your face or body? *YesNoSpecify: *5. Have you ever had chemical peels, laser or microdermabrasion? *YesNoIn the last month? *YesNo6. Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products? *YesNoDescribe: 7. Have you used any of these products in the last 3 months?YesNo8. Have you used an acne medication? YesNoWhen?Which drug?SoapShower GelsTonerBody Lotions MaskSunscreenEye ProductSPFCleanserNight Moisturizer/CreamDay MoisturizerOtherExfoliatorMakeup Products Scrubs 9. What skin care products are you currently using? (List brand where known)10. Have you recently used any self-tanning lotions, creams or treatments?NoYesSpecify11. Have you used any of the following hair removal methods in the past six weeks?NoYesCircle all that applyShaveWaxingElectrolysisPluckingTweezingStringingDepilatories12. What areas of concern do you have regarding your SkinBreakouts/acne Blackheads/whiteheads Excessive oil/shine RosaceaBroken capillaries Redness/ruddiness Sun spot/liver spot/brown spot Uneven skin tone Sun damage Wrinkles/fine linesDull/dry skin Flaky skin DehydratedOtherPlease check any that apply and explainOther *Eyes:DehydratedWrinklesPuffinessDark CirclesOtherOtherLipsDehydratedCracked/Chapped LipsOtherOther13. Have you ever had an allergic reaction to any of the following? *NoYesPlease check any that apply and explain *CosmeticsMedicine Food Animals Sunscreens Iodine Pollen AHAs Fragrance Shellfish Latex Drugs OtherPlease Explain *16. Have you had any recent tanning bed or sun exposure that changed the color of your skin? NoYesSpecify Pelase17. Have you experienced Botox, Restylane or Collagen injections? *NoYesSpecify Pelase *Please use this space to complete answers where space was insufficient. *(Please include the number of the question) May I call you at your home, work or cell phone number to confirm future appointments? *YesNoMay I contact you via mail/email about future promotions and news? *YesNoCheckboxes *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 SignatureDate *Submit
