Skincare and Facial Consultation & Consent Form

PrefixMr.Mrs.Ms.Mx.MissDr.Prof.

First Name *

Middle Name

Last Name *

Date of Birth

Phone Number *

Email Address *

How did you hear about us?GoogleInstagram/FacebookFriendOther*

Have you had a facial before?YesNo

What is your main focus/concern? Is there anything you would like to specifically focus on?0 / 180

What skin care products are you currently using? (including any topicals prescribed from a doctor or dermatologist, make-up; primer, foundation, etc.) 0 / 180

Are you interested in learning about new products/skincare regimen? YesNo

Is dairy a part of your diet? If yes, what kind of dairy (i.e. milk, cheese, yogurt..) and how often do you consume dairy? *0 / 180

In the past three months, have you received any of the following treatments or used any of the following products? *Alpha Hydroxy Acids (Glycolic or Lactic Acids)Hydroxy Acids (salicylic acids)Retinol or Retin-AApricot ScrubLaserMicrodermabrasionMicrobladingChemical PeelsFacial WaxingBenzoyl PeroxideNone of the above

Approximately how many glasses of water do you consume daily? *12345678910

Approximately how many caffeinated beverages do you consume daily? *12345

Do you smoke cigarettes?YesNo

If you experience acne/break outs, what areas of the face do you break out the most?0 / 180

Do you exfoliate? YesNo

How often do you exfoliate?0 / 180

Do you consider yourself to have any of the following? *TightnessRednessFine lines/WrinklesDryness/FlakinessSensitivitiesVisible CapillariesBlackheadsActive Break-outs, pimples/pustules

Any known allergies?0 / 180

Female Clients

Are you taking birth control?YesNo

Are you pregnant?YesNo

Are you going through menopause?YesNo

Have already experienced menopause?YesNo

Client History

Have you been to a dermatologist in the last 6-12 months?YesNo

If you have seen a dermatologist in the last 6-12 months, what was it for, and were you prescribed any topical or oral medications?0 / 180

Do you have any of the following issues?CancerHormonal ImbalancesPsoriasisCold SoresHigh Blood PressureThyroidRecent SurgeriesMetal ImplantsEczemaNone of the above

Date

Hours

Minutes

AMPM

Consent Form

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