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Client Consultation Form
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Email
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Your email
Full Name:
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Your answer
DOB:
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Your answer
Gender:
Your answer
Phone Number:
*
Your answer
Email Address:
*
Your answer
Address:
*
Your answer
Emergency Contact:
*
Your answer
How did you hear about us?
*
Your answer
Are you currently under the care of a doctor or dermatologist? If yes, provide details.
Your answer
Have you been diagnosed with any of the following conditions?
Diabetes
High/Low Blood Pressure
Heart Conditions
Epilepsy
Allergies
Autoimmune Diseases
Skin cancer
Rosacea
Eczema or Psoriasis
Lupus
Hormonal imbalance (PCOS, Menopause, etc.)
Pregnancy/Breastfeeding
Are you currently taking any medications (oral or topical)? If yes, please list:
Your answer
Have you had any recent surgeries, including cosmetic procedures? If yes, please list:
Your answer
Do you have any metal implants, pacemakers, or medical devices?
Yes
No
Clear selection
Do you smoke or vape?
Yes
No
Clear selection
Do you drink alcohol?
Yes
No
Clear selection
What are your main skin concerns? (Check all that apply):
Acne/Breakouts
Acne Scarring
Hyperpigmentation
Dryness/Dehydration
Oiliness
Redness/Inflammation
Wrinkles/Fine Lines
Loss of Firmness
Sun Damage
Uneven Texture
Dark Circles
Sensitive Skin
How would you describe your skin type?
Normal
Dry
Oily
Combination
Sensitive
Clear selection
Have you ever had any adverse reactions to skincare treatments or products? If yes, please explain:
Yes
No
Clear selection
What skincare products are you currently using? (Cleanser, Toner, Moisturizer, SPF Serums, Treatments)
Your answer
Have you had any of the following treatments in the past 6 months? (Check all that apply):
Facials
Chemical Peels
Microneedling
Laser Treatments
Botox/Fillers
Dermaplanning
Microdermabrasion
IPL/ Photofacials
Are you using any prescription skincare (Retinol, Hydroquinone, Accutane, etc.)? If yes, please list:
Your answer
Do you use sunscreen daily?
Yes
No
Clear selection
How many hours of sleep do you get per night?
Your answer
Do you exercise regularly?
Yes
No
Clear selection
How much water do you drink daily?
Your answer
Do you follow a specific diet? (Keto, Vegan, Gluten-Free, etc.)
Your answer
Are you currently experiencing high levels of stress?
Yes
No
Clear selection
Do you wear makeup daily?
Yes
No
Clear selection
If yes, do you remove it thoroughly at night?
Yes
No
Clear selection
I acknowledge that all treatments provided by the aesthetician are non-medical in nature. I understand the risks and benefits of the services I receive.
*
Agree
Required
I authorize the spa to take before and after photos for progress tracking and marketing purposes.
*
Yes
No
I understand that I must provide 24 hours’ notice to cancel or reschedule an appointment to avoid any fees. Cancellations day of will be charged 100%. Cancellations made within 24hrs of scheduled appointment will not be charged.
*
Agree
Required
I understand that my personal information will be kept confidential and used only for spa-related purposes.
*
Yes
A copy of your responses will be emailed to the address you provided.
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