Client Consultation Form
Please complete and submit this form at least 2 days prior to your treatment.
* Required
First Name
*
Your answer
Last Name
*
Your answer
Phone Number
*
Your answer
Email
*
Your answer
Date of Birth
Your answer
Occupation
Your answer
Skin Care
Today my skin feels:
*
Dry
Dehydrated
Sensitive/Irritated
Oily/Congested
Normal
Combo/Oily
Combo/Dry
Itchy/Flaky
Required
My skin could use improvement in:
*
Skin Texture
Fine Lines/Wrinkles
Firmness/Elasticity
Premature Aging
Rosacea (redness)
Acne (blemishes)
Pores (large)
Discoloration/Dark Spots
Sun Damage
Other:
Required
Does your A.M. skin care routine involve any of the following:
*
Cleanse
Toner
Moisturize
Exfoliate
Mask
Other:
Required
Does your P.M. skin care routine involve any of the following:
*
Cleanse
Toner
Moisturize
Exfoliate
Mask
Other:
Required
Please list product names for any of the above products you are currently using.
*
Your answer
Are you interesting in changing/purchasing new skin care products?
*
Yes
No
Unsure/Maybe
Do you use sunscreen?
*
Yes
No
What brand of sunscreen do you use?
*
If none, write N/A.
Your answer
Health & Wellness
Are there any health/medical concerns or allergies I need to be aware of today? Please elaborate if yes.
*
Your answer
Are you currently taking any vitamins, supplements, herbs, prescription, nonprescription medications or remedies? Please list if yes.
*
Your answer
Are you currently undergoing cancer treatment? If yes, please bring a note from your medical provider to your session.
*
Yes
No
Thyroid Health
*
Normal
Abnormal
Are you pregnant?
*
Yes
No
Maybe
Are you:
*
Menstruating
Menopausal
Post-Menopausal
Please list 2 emotions that seem predominant in your life today:
*
Your answer
Essential oil/fragrance preferences?
*
(i.e. lavender, rose, lemon, sage, etc.?)
Your answer
What is your favorite color?
*
Your answer
My energy level is:
*
High
Moderate (balanced)
Low
Areas of tension in my body:
*
Neck/Shoulders
Torso/midback
Lower back/hips
Arms/hands
Legs/feet
None
Required
My overall body temperature feels:
*
Cool
Warm to hot
Cold with poor circulation
Diet: Please indicate how often you eat the following foods
Red Meat
*
Often
Occasionally
Rarely
Never
Poultry
*
Often
Occasionally
Rarely
Never
Fish
*
Often
Occasionally
Rarely
Never
Vegetables
*
Often
Occasionally
Rarely
Never
Grains
*
Often
Occasionally
Rarely
Never
Fruit
*
Often
Occasionally
Rarely
Never
Nuts/Seeds
*
Often
Occasionally
Rarely
Never
Seaweeds
*
Often
Occasionally
Rarely
Never
Dairy
*
Often
Occasionally
Rarely
Never
Honey
*
Often
Occasionally
Rarely
Never
Sugar
*
Often
Occasionally
Rarely
Never
Fermented Foods
*
Often
Occasionally
Rarely
Never
Raw Foods
*
Often
Occasionally
Rarely
Never
Tea
*
Often
Occasionally
Rarely
Never
Coffee
*
Often
Occasionally
Rarely
Never
Alcohol
*
Often
Occasionally
Rarely
Never
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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