consultation form Name * First Name Last Name Email * Address * This is where the service will take place. Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Sex * Female Male Other How were you referred to us? Occupation * Does your job require that you work outdoors? * Yes No What would you like to achieve from your treatment today? Have you ever had a facial treatment before? * No Yes Have you ever had a body spa treatment before? * No Yes Which of the following best describes your skin type? * Type I Fair skin tones—Always burns, never tans Type II Light skin tones—Burns easily, tans slightly Type III Fair to olive skin tones—Burns moderately, tans moderately Type IV Light brown skin tones—Burns slightly, tans easily Type V Dark brown skin tones—Rarely burns, tans easily Type VI Dark brown to black skin tones—Never burns, tans easily Do you have any special skin problems or concerns pertaining to your face or body? * No Yes Have you ever had chemicals peels, laser treatments, or microdermabrasion? * No Yes Do you use Accutane, Retin-A, Renova, Adapalene Hydroxyl Acid or any other Retinol/vitamin A derivative products? * No Yes Have you used acne medication? * No Yes Have you experienced Botox, Restylane, or collagen injections? * No Yes What skin care products are you currently using? (List brands if known) * Please list all products including cleanser, toner, moisturizer, exfoliant, masks, scrubs, etc. Have you used any hair removal methods in the past six weeks? * No Yes Do you experience irritation from shaving? * No Yes What areas of concern do you have regarding your skin? * Breakouts/acne Sun damage Rosacea Flaky skin Sun/liver/brown spots Uneven skin tone Excessive oil/shine Dull/dry skin Redness/ruddiness Blackheads/congestion Wrinkles/fine Lines Broken capillaries Dehydration Other Are you allergic to any of the following? * Cosmetics Fragrance Animals AHAs Food Latex Iodine Medication Shellfish Sunscreens Pollen Plants/Trees No known allergies Other If yes, please specify Thank you!
