BLK BMR Skin Bar Client Consultation Form
7520 Montgomery Blvd NE Suite C2 Albuquerque, NM 87110.  

***Front Door Facing Pennsylvania RD Side  (Part of Sage Beauty Studios BLDG C. DO NOT Enter on Endotontics Side) 

510-993-5555
www.blkbmr.com
Email *
Full Name *
Birthday Month/Year *
Address *
Phone *
Email *
Emergency Contact and Phone Number *
Are you currently under a physician's care?  Do you have any contraindications to receiving any of the services BLK BMR provides? 

Facials, Red Light Therapy, Enzyme Peels, Massage, Microdermabrasion, Microneedling, Microchanneling, Dermaplaining, Radio Frequency?  If yes please answer the next question.  

Auto-Immune, Cancer, Heart Patient, Scleroderma, Fungal Infection etc.
 *
Medical concerns: *
Required
List any allergies (including fish, plants, or common facial ingredients): *
Are you pregnant or nursing? *
Skincare Routine & Habits.  Check all that apply and discuss with your skin care specialist *
Required
What are your skincare goals?  This will be a journey not a race.   *
Required
Do you wear Broad Spectrum UVA/UVB SPF daily? *
How many ounces of water do you drink daily? *
Do you use exfoliation with abrasive/sand/gritty ingredients? May thin skin barrier *
Do you use Accutane or Retinol? Please stop 5 days before Microneedling.  When did you last use it? Retinol and Accutane thins the skin barrier so extra precaution must be taken to repair the skin barrier first. *
Has microneedling or laser ever caused pigmentation changes for you?
 *
I acknowledge BLK BMR Front door OPENS on Pennsylvania Road Side :-) 

Located INSIDE of Sage Beauty Studios not Endotontic Office :). 

Parking in front of Sage Beauty Studio Sign

Sorry GPS takes everyone to the wrong door so I added this in for clarification.  
 *
CONSENT:

I have answered the  questions accurately.  

I understand that skincare treatments have varying results and that my skin may react to certain procedures. 

I will follow aftercare instructions to maintain desired results and minimize side effects.  

I understand one service will provide a kick start to skin health but multiple services may be required to achieve desired results.  

Type your Full Name
 *
Date *
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Aftercare Instructions
1. Avoid touching or picking at your face for at least 24 hours. 
2. Apply SPF daily and avoid direct sun exposure for 48 hours. 
3. Do not use acne/acid exfoliating products, retinol, or acids for 5-7 days. 
4. Avoid heavy make-up, hot showers, saunas, and intense exercise for 24 hours. 
5. Use gentle, hydrating skincare as recommended by your esthetician.  
5a For Microneedling or Microchanneling: NO SPF, Creams, Oils or Essential Oils, fragrances, Fruit Acids or pore clogging products for 48 hours.  Acne will result.  
6. Stay hydrated and avoid alcohol, smoking for optimal skin healing.
7. Keep all hair off of face also
8. Wipe your phone and glasses with alcohol
A copy of your responses will be emailed to .
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