Facial Consultation Form

Personal Information

Name *

Date *

Phone *

Email *

Date of Birth *

Age *

Gender *

Female
Male
NB

Address *

Address Line 1

City

State

Emergency Contact *

Phone # *

How did you hear about us?

be products? used

Would you like to be added to our email list for news and exclusive offers? *

Yes
No

Medical History

Do you have or have you had any of the following conditions? If yes, please select them:

Medical History *

Any other condition?

Any known allergies? *

Yes
No

If yes, what are you allergic to?

List any medications you take regularly, including vitamins, herbal supplements, aspirin:

Any recent surgery, including plastic surgery? *

Yes
No

If yes, please specify

Are you pregnant or trying to become pregnant? *

Yes
No

Skin History

Have you ever had a facial treatment before? *

Yes
No

If yes, please explain

What would you like to achieve from your treatment today? *

What is your skin type? *

Your exposure to the sun? *

Never
Light
Moderate
Excessive

What type of foundation do you wear? *

Liquid
Cream
Powder
None

How does your skin heal? *

Fast
Slow
Scars
Pigments

Do you get bruises easily? *

Yes
No

Please Check Current Products You Use

Please Check Current Products You Use *

Have you ever used acne medication? *

Yes
No

If yes, when? (copy)

Which drug?

Have you in the last 3 months used Retin-A, Renova, AHA's or Retinol/Vitamin A derivative products? *

Yes
No

If yes, please describe

Have you received Botox,Restylane or Collagen injections in the last 6 months? *

Yes
No

If yes, please specify

By signing below, you agree to the following:

I have completed this form truthfully and to the best of my knowledge. I agree to inform the technician of any changes in the above information. I agree to waive all liabilities toward my technician and the employer for any injury or damages incurred due to any misrepresentation of my health history.

Client Name (Printed) *

Date *

Signature *

Clear Signature