Client Consultation Form
Please complete and submit this form at least 2 days prior to your treatment.
First Name *
Last Name *
Phone Number *
Email *
Date of Birth
Skin Care
Today my skin feels: *
My skin could use improvement in: *
Does your A.M. skin care routine involve any of the following: *
Does your P.M. skin care routine involve any of the following: *
Please list product names for any of the above products you are currently using. *
Are you interesting in changing/purchasing new skin care products? *
Do you use sunscreen? *
What brand of sunscreen do you use? *
If none, write N/A.
Health & Wellness
Are there any health/medical concerns or allergies I need to be aware of today? Please elaborate if yes. *
Are you currently taking any vitamins, supplements, herbs, prescription, nonprescription medications or remedies? Please list if yes. *
Are you currently undergoing cancer treatment? If yes, please bring a note from your medical provider to your session. *
Thyroid Health *
Are you pregnant? *
Are you: *
Please list 2 emotions that seem predominant in your life today: *
Essential oil/fragrance preferences? *
(i.e. lavender, rose, lemon, sage, etc.?)
What is your favorite color? *
My energy level is: *
Areas of tension in my body: *
My overall body temperature feels: *
Diet: Please indicate how often you eat the following foods
Red Meat *
Poultry *
Fish *
Vegetables *
Grains *
Fruit *
Nuts/Seeds *
Seaweeds *
Dairy *
Honey *
Sugar *
Fermented Foods *
Raw Foods *
Tea *
Coffee *
Alcohol *
Things to keep in mind:
• Payment: Cash or check accepted at the time of your appointment.
• Please refrain from wearing perfume and make-up to appointments.
• If wearing contacts, please remove them before facial treatment.
• Please be on time. I cannot guarantee full treatment time if you arrive late.
• Cancelation Policy: If you need to cancel or reschedule your appointment, please do so with at least 24 hours notice. Otherwise, you will be charged in full for the treatment.
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