FACIAL & WAXING CONSULTATION FORM
In order for us to create the most effective and safe treatment plan that is customized just for you, we must collect certain personal and medical information. PURE Skincare & Acne Spa will never share or disclose any information that you share with us.
First and Last
Who were you referred by?
(google, yelp, family, friend, etc)
Which of the following best describes your skin type?
Light Complexion: Always burns easily, never tans
Fair Complexion: Always burns, tans slightly
Medium Complexion: Burns moderately, tans gradually
Olive Complexion: Seldom burns, always tans well
Brown Complexion: Rarely burns, deep tan
Black Complexion: Never burns, deeply pigmented
Have you ever had a facial or skincare treatment?
If yes, which treatments have you received and how recently?
Such as: Facials, Acne Treatments, Lash Extensions, Chemical Peel, Microdermabrasion, Laser, Botox, Fillers, etc
Have you ever been waxed or had another form of hair removal done?
If yes, which treatments and how recently?
Such as waxing, sugaring, threading, electrolysis or laser hair removal, etc
Please list any known allergies:
Please inform us of any Prescribed, Over the Counter and Recreational Drug/Medications (past and present use):
Clindamycin Topical or Oral
Acne Medications Topical or Oral
Retin A Cream or Gel
None of these
Which of these best describes your current home skin care routine?
KEEP IT SIMPLE: One or two products and I'm good to go
HIT OR MISS: Sometimes I'm consistent, sometimes I'm not
DAILY ROUTINE: Consistent with daily routine, which includes several products morning and night
Describe the products you use morning and night:
Cleanser, Toner, Serums, Moisturizers, SPF, Mask, Foundation, Blush, Exfoliant (ex. Glycolic), Acne Medications, etc. (Please write product name)
Have you used any Alpha Hydroxy Acid (AHA) or Beta Hydroxy Acids (BHA) in the past 48-72 hours?
Such as glycolic, lactic, salicylic, mandelic, etc
I'm not sure
Are you exposed to the sun on a daily basis or do you use a tanning bed?
Have you tanned in the last 24 hours?
Have you ever had a reaction to a skin care product, treatment or waxing? (Please Explain)
Check any condition you currently have or may have had in the past two years.
HIV+ or AIDS
Thrombosis/ Blood Clot/ Stroke
Herpes Simplex/ Cold Sores
Hysterectomy/ Ovaries removed
Pregnant, Nursing or trying to become Pregnant
High Blood Pressure
None of these
Are you under a Dermatologist's care?
Are you currently under a lot of stress?
I'm always under stress! Who isn't?
I get stressed out every once in a while.
Nope- Totally stress free!
What are your biggest skin care concerns?
Fine Lines or Wrinkles
Sun Spots/ Hyperpigmentation
Dry or Rough Skin
Razor Bumps or Shaving Irritation
Do you consider your skin:
Last but not least, what results would you like to obtain with your skin?
TREATMENT CONSENT: I hereby consent to and authorize Holly Roth, Licensed Esthetician, to perform the requested services. I have voluntarily elected to undergo this treatment/procedure after the nature and purpose of this treatment has been explained to me, along with the risks and hazards involved. Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications. I also recognize there are no guaranteed results and that independent results are dependent upon age, skin condition, and lifestyle and that there is the possibility I may require further treatments of the treated areas to obtain the expected results at an additional cost. I have read and understand the post-treatment home care instructions. I understand how important it is to follow all instructions given to me for post-treatment care. In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult the esthetician immediately. I have also, to the best of my knowledge, given an accurate account of my medical history, including all known allergies or prescription drugs or products I am currently ingesting or using topically. I have read and fully understand this agreement and all information detailed above. I understand the procedure and accept the risks. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I do not hold Holly Roth or Pure Skincare & Acne Spa responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment/s performed at my appointment/s.
By selecting "Yes", I agree and understand the information provided. We will be unable to provide a treatment if consent terms are not accepted.
Yes, I accept
No, I do not accept
CANCELLATION POLICY: If you need to reschedule or cancel an appointment, I require a minimum of 24-hours notice. Please call or text (989) 307-9369. If there is no answer, please leave your information on the voice mail and/or text your cancellation as proof of your cancellation contact. I do understand that things happen beyond our control and will do my best to accommodate your needs. My online booking system sends out 2 reminders, 48 and 24 hours in advance. Please understand that it is your responsibility to remember your appointment dates and times to avoid late arrivals, missed appointments and any cancellation fees. Clients that "no show" appointments or give less than 24 hours notice may be invoiced a cancellation fee equal to 50% of their scheduled service, which would need to be paid before booking future appointments, and repeat offenders may be required to pay in advance for future services. Because Pure Skincare & Acne Spa is by appointment only, your appointment time is reserved exclusively for you and I request that you please respect the cancellation policy. LATE ARRIVALS: If you arrive late, your session may be shortened in order to accommodate others whose appointments follow yours. Depending upon how late you arrive, I will then determine if there is enough time remaining to start a treatment. Regardless of the length of the treatment actually given, you will be responsible for the full session. Out of respect and consideration to me and other customers, please plan accordingly. Thank you for understanding!!
By selecting "Yes", I agree and understand the information provided. We will be unable to provide a treatment if cancellation terms are not accepted.
Yes, I accept
No, I do not accept
Page 1 of 1
Never submit passwords through Google Forms.
This form was created inside of PURE Skincare & Acne Spa.