FaceMode New Client Consultation Form
This form is to be filled out only if you scheduled your Skin consultation appointment through stylseat! This process helps with utilizing the whole 30 minutes for your consultation, instead of using 5-10 minutes of filling out the paper form.
Date
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Name *
Your answer
Date of birth
MM
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DD
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YYYY
Contact number *
Your answer
Email *
Your answer
How did you hear about FaceMode?
Who referred you?
Your answer
What are your primary skin care concerns?
Your answer
What are your skin care goals?
Your answer
Have you ever had a facial treatment before?
If yes, when?
Your answer
Have you ever had (Check all the apply)
Any cosmetic procedure in the last 30 days?
Your answer
Are you currently using prescription topical?
If yes, please list them below
Your answer
Have you taken Accutane in the last 6-12 months?
If yes, what is the dosage?
Your answer
Have used an acne medication?
If yes, when? and which drug?
Your answer
Have you used any of the following hair removal methods in the past six weeks?
What skin care products are you currently using? List brand below
Cleanser
Your answer
Exfoliant (How many times per week)
Your answer
Toner
Your answer
Hydrator/moisturizer (Day & Night)
Your answer
Serum/eye serum
Your answer
Daily sunscreen/SPF
Your answer
Mask
Your answer
Other
Your answer
What areas of concern do you have regarding you skin? (Please check any that apply)
Have you had any recent tanning bed or sun exposure that changed the color of your skin?
If yes, specify
Your answer
When was your last sun burn?
Your answer
General Health
Do you have any health conditions that could affect your treatment?
If yes, please explain
Your answer
Do you have metal or any medical implant of any kind?
Have you ever had a allergic reaction to any of the following? (Please check all the apply )
Have you experience an allergic reaction to Asprin?
Do you exercise?
If yes, how often?
Your answer
Do you smoke?
Do you consume sugar, dairy, meat, spicy foods daily?
FEMALE ONLY
Are you taking oral contraceptives?
If yes, please specify
Your answer
Any recent changes to or from you contraceptive treatment?
If so, what and when?
Your answer
Are you pregnant or trying to become pregnant?
Are you lactating?
Any menopause problems?
Are you undergoing any hormone replacement therapy?
MALE ONLY
What is your current shaving system?
Do you experience irritation from shaving?
Do you experience ingrown hairs?
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that is supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof. CLIENT SIGN BELOW! *
Your answer
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