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New Client Consultation Form

What are your skin care challenges? Required
Do you/have you used Retin-A, Renova, Adapalene, Acctane, Differin, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivatives? Required
Have you received any Botox, Juvederm, or other injectables in the last two weeks? Required
How did you hear about me? Required
Have you ever had a facial or skin treatment before?
Which of the following best describes your skin type? Required
What skincare products do you currently use? Required

Please detail the SPECIFIC products (BRAND & PRODUCT TYPE/NAME) you are currently using so I can best answer any questions on ingredients and help you meet your skin care goals.

Have you received any of these hair removal services in the last 30 days? Required
Have you ever received Chemical Peels, Laser Servies or Microdermabrasion treatments? Required

YOUR HEALTH

Have you ever experieced any of these health conditions in the past or present? Required
Do you? Required
Have you used or been prescribed any medications (topical or oral) for acne/acne control? Required
Do you use SPF? Required
Are you a smoker? Required
Please rate your stress level: Required
Have you ever experienced claustrophobia? Required

FEMALE CLIENTS

Are you pregnant or trying to become pregnant? Required
Are you taking birth control? Required
Any known allergies? Required
Do you take any of the following dietary/health supplements? Required
Any menopause issues? Required
Are you undergoing any hormone replacement therapy? Required

MALE CLIENTS

What is your current shaving system?
Do you experience irritation from shaving?

Post Facial Care/Waxing Instructions: Aerobic exercise and/or vigorous physical activity should be avoided for 48 hours. Direct sunlight exposure is to be avoided immediately following the treatment (including any strong UV light exposure and/or tanning beds). If some sun exposure cannot be avoided, apply a broad spectrum sunscreen of SPF 30+. Sunscreen (with a minimum of SPF 15 should become party of your daily skin care regimen as skin can potentially become more sensitive to the sun as a result of this treatment. Unless otherwise specified, in the evening following your treatment, cleanse your skin with a mild cleanser and water followed by a non-active moisturizer. Do not apply additional exfoliating ingredients/products the day of your service as over-exfoliation can result in irritation or further sensitivity. Consult your skin care professional before resuming topical treatments. Enzyme peels, DermaFile, or DermaDisc treatments, chemical peels, or facial waxing can result in skin flushing/redness, or slight skin flaking or sensitivity for up to 48-72 hours post-treatment. DO NOT peel, pick, rub, or scratch your skin at any time, whatsoever. This can potentially cause damage or compromise your results.

Reservation & Cancellation Policy for all current and future appointments: A valid credit card is required for all appointments. Please do not forget to confirm your appointment when you receive your reminder. In the event of cancellations received less than 24 hours prior to appointment, a cancellation fee equal to the reserved service booking will incur. No shows will be charged 100%.

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that witholding 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 skin care professional from liability and assume full responsibility thereof.

Thanks for submitting!

contact

Rhonda@theintuitivebeauty.com

831-677-6161

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