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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.
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What is your name? *
What is the month and year you were born? *
What is your mailing address? *
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? *
What is your preferred method of communication? *
What is you hereditary background? *
What is your occupation? *
Do you work around chemicals, tars, oils or inks? *
Describe how YOU see and feel the skin on your face? *
Required
Do you have an upcoming event you are planning for? *
On a scale from 1 to 10, how concerned are you about seeing change in your skin? *
Not Concerned
Very Concerned
If you are experiencing ACNE does anyone in your family previously or currently suffer from the same condition?
ACNE Clients - What age did your acne start?
ACNE Clients - How long have you been dealing with your acne?
ACNE Clients - How is acne affecting your lifestyle? Do you miss out on special occasions, activities, other social events?
ACNE Clients - What are your top areas of concern?
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Do you pick at your skin? *
List brand, name and usage for all topical applied products. Pretend you are writing in your diary and be AS SPECIFIC AS POSSIBLE. We love all the juicy details! *
Have you ever had any adverse reactions to any of the above products, or any product you have put on your face? *
Have they achieved the results you want? *
On a scale of 1 to 10, how willing are you to modify current habits, activities, and/or regimens in order to support and/or enhance your skin transformation? *
Not willing
Very willing
What do you want to change about the skin on your face? *
Required
If you checked "FACIAL" what is the thing you loved most & least about it? *
List current medications including birth control pills and herbal supplements or vitamins? *
Have you ever used any of the following topical or oral medications? *
Required
Have you had any of the following? *
Required
How many hours of sleep do you get each night? *
How frequently do you exercise? *
What is the intensity of you exercise activity? *
Required
What is your daily stress level? *
How do you relieve stress? *
What is your diet like? *
Required
Do you suffer from claustrophobia or anxiety? *
Do you use fabric softener or fabric softener sheets in the dryer? *
Do you have any allergies or sensitivities? *
Required
Past or current cycle issues? *
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? *
Do you smoke? If yes, how many per day? *
How much caffeine do you intake per day? *
How much alcohol do you consume (daily/weekly/monthly)? *
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?
Do you swim regularly? *
Required
Have you ever had severe headaches or migraines? *
Required
Would you like more information on or are interested in:
How were you referred to Exfolē8 *
Do you understand that after some procedures/treatments there may be some down time to allow the skin to heal? *
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 adverse skin reactions from treatments of products received. I am aware that it is my responsibility to inform the esthetician/skin care therapist of my current medical or health conditions and to update this history when necessary. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof. *
Is there any information you would like to tell us that was not covered on the questionnaire?
I am here because I want to know more about... *
Required
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Skin (face or body) photos are taken to monitor treatment progress and are stored in your chart. At times, employees of Exfolē8, Inc. may ask your permission to take photos or make a video in order to showcase a treatment experience, new service(s), or share before & after photos of your results. Are you allowing Exfolē8, Inc. permission to share your photos or videos on Social Media, in marketing material or client newsletters to highlight your results or experience? Please select your photo permission preference? *
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