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FACIAL TREATMENT
CONSULTATION FORM
First name
Last name
Email
Phone
Birthday
*
required
Gender?
*
Female
Male
Nonbianary
Street Address
City
Region/State/Province
Postal / Zip code
Your Occupation
Would you like to be added to our email list for news and exclusive offers?
Any known Allergies?
*
Required
Yes
No
If Yes:
List any medications you take regularly:
Any recent surgery, including plastic surgery?
*
Required
Yes
No
If yes, please explain:
Are you pregnant or trying to become pregnant?
*
Required
Yes
No
Have you ever had a facial treatment before?
*
Required
Yes
No
If yes, please explain:
What would you like to achieve from your treatment today?
Please check any current products you use:
*
Required
Eye Make-Up Remover
Eye Cream
Mask
Cleansing Cream
Day Cream
Facial Scrub
Facial Soap
Night Cream
Exfoliants
Skin Toner/ Astringent
Neck lotion
Body Lotion
Body Soap
Hand cream
Body Scrub
Do you have any skin concerns?
*
Required
Acne
Blackheads
Broken Capillaries
Comedones
Cherry Angioma
Discoloration
Dryness/Dull Skin
Eczema
Fine lines/Wrinkles
Hyper pigmentation
Hypo pigmentation
Keloids
Milia
Oily Skin
Psoriasis
Redness
Rosacea
Scarring
Sensitivity
Sun Damage
Thin Skin
Unwanted Hair
What is your skin type?
*
Required
Normal
Oily
Dry
Combo
Unsure
Your exposure to the sun?
*
Required
Never
Light
Moderate
Excessive
What type of foundation do you wear?
*
Required
Liquid
Cream
Powder
None
How does your skin heal?
*
Required
Fast
Slow
Scars
Pigments
Do you bruise easily?
*
Required
No
Yes
Have you ever used acne medication?
*
Required
No
Yes
If Yes, when & which medication?
Have you in the last 3 months used Retin-A, Renova, AHA's or Retinol/Vitamin A derivative products?
*
Required
No
Yes
Have you received Botox, Restylane, or Collagen injections in the last 6 months?
*
Required
No
Yes
By checking this box, you agree to the following: I have completed this form truthfully and to the best of my knowledge. I agree to inform the technician of anychanges in the above information. I agree to waive all liabilities toward my technician and the employer forany injury or damages incurred due to any misrepresentation of my health history.
SUBMIT CONSULT FORM
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