Client Consultation Form
Please complete and submit this form at least 2 days prior to your treatment.
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:
Required
My skin could use improvement in:
Required
Does your A.M. skin care routine involve any of the following:
Required
Does your P.M. skin care routine involve any of the following:
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?
Do you use sunscreen?
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.
Thyroid Health
Are you pregnant?
Are you:
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:
Areas of tension in my body:
Required
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.
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms