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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? *
What is your date of birth? *
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? *
Please describe how YOU see and feel the skin on your face? *
Required
If you are experiencing acne, does anyone in your family previously or currently suffer from the same condition?
Please list product brand, product name and usage. *
Have they achieved the results you want? *
What do you want to change about the skin on your face? *
Required
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
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
If you checked "FACIAL" what is the thing you loved most & least about it? *
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? *
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?
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 *
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?
I am here because I want to know more about... *
Required
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