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Exfolē8 Skincare Consultation Form
Hello. We are requesting that our consultation form be sent back at least 24 hours before your scheduled appointment time. This is help us to learn about your skin concerns and expectations. It will also allow us time to look up important information such as: medications, illness, allergies, current regime and plan accordingly for pregnant clients. We look forward to providing you with the best possible service. If you have any questions, concerns or requests please let know. Thank you.
What is your name? *
Your answer
What is your date of birth? *
MM
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DD
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YYYY
What is your mailing address? *
Your answer
Would you like to be placed on our email mailing list (no more than 2x per month) to receive notifications about specials, last minute savings or new services etc? *
Required
What is your phone number? *
Your answer
What is you hereditary background? *
Your answer
What is your occupation? *
Your answer
Please describe how YOU see and feel the skin on your face? *
Required
What do you want to change about the skin on your face? *
Required
Please list product brand, product name and usage. *
Your answer
Have they achieved the results you want? *
List current medications including birth control pills and herbal supplements or vitamins? *
Your answer
Have you ever used any of the following topical or oral medications? *
Required
Would you like more information on or are interested in:
Do you suffer from claustrophobia or anxiety? *
Have you had any other the following? *
Required
Do you have any allergies or sensitivities? *
Required
Have you ever had Cold Sores/Fever Blisters? *
Have you ever had Diabetes? *
Have you ever had Hepatitis? *
Have you ever had a heart condition? *
Have you ever had HIV/AIDS? *
Do you have metal implants or a pacemaker? *
Do you or have you had any form of Cancer? *
Have you had any Thyroid disorders? *
Do you have MRSA? *
Do you have Tuberculosis? *
Do you currently have symptoms of a communicable illness? *
Are you prone to seizures? *
How much water do you consume daily? *
Your answer
Do you smoke? If yes, how many per day? *
Your answer
How much caffeine do you intake per day? *
Your answer
How much alcohol do you consume (daily/weekly/monthly)? *
Your answer
Are you in the habit of using tanning booths? *
Are you currently sunburn? *
Are you pregnant or breastfeeding? *
Required
Do you have any other medical issues? *
Required
Would you like to add any waxing to your service today? If so, where?
Your answer
What is your diet like? *
Required
Do you swim regularly? *
Required
Have you ever had severe headaches or migraines? *
Required
How were you referred to Exfolē8 *
Your answer
Do you understand that after some procedures/treatments there may be some down time to allow the skin to heal? *
Is there any information you would like to tell us that was not covered on the questionnaire?
Your answer
I am here because I want to know more about... *
Required
Exfolē8 requires notice of a cancellation 24 hours prior to your scheduled appointment via the phone, email or online booking agent. An appointment reminder will be sent via email or text 48 hours prior to the scheduled appointment. As a courtesy, please confirm (click the green button) your appointment. If you do not contact Exfolē8 to reschedule or do not show up to your appointment, you will be charged 100% of your scheduled service(s) to the card we have on file. Late cancellations (see below for updated policy) result in a 50% charge of your scheduled services to the card we have on file. You will have two weeks (14 days) to reschedule your appointment via phone or email or online booking agent. If there is a remaining amount for your service(s), then the difference will be charged after you enjoy your rescheduled appointment. New Policy: If you cancel your appointment within 3 hours of your appointment time you will be charge the full amount of your service. If you reschedule your appointment within 3 hours of your service you will be charged a $10 cancellation fee and the appointment must be rescheduled within 7 days. If not rescheduled in seven days, you will be charged the full amount for the cancelled service. Do you agree to your cancelation policy? *
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