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Client Consultation Form

Sex: Required
Does your job require that you work outdoors? Required
Have you ever had a facial treatment before? Required
Have you ever had a body spa treatment before? Required
Which of the following best describes your skin type? (Please check one) Required
Do you have any special skin problems or concerns pertaining to your face or body?* Required
Have you ever had chemicals peels, laser treatments, or microdermabrasion? Required
In th last month? Required
Do you use Accutane, Retin-A, Renova, Adapalene Hydroxyl Acid or any other Retinol/vitamin A derivative products? Required
Have you used acne medication? Required
Have you experienced Botox, Restylane, or collagen injections? Required

What skin care products are you currently using? (List brands if known)

Have you used any hair removal methods in the past six weeks? Required
Select below: Required
What areas of concern do you have regarding your: Skin (Check all that apply) Required
Eyes (Check all that apply) Required
Lips (Check all the apply) Required
Have you ever had an allergic reaction to any of the following (Check all that apply) Required
Have you recently used any self-tanning lotions, creams or treatments? Required
Have you had any recent tanning bed or sun exposure that changed the color of your skin? Required

LIFESTYLE

How many glasses of water do you drink per day? (Please check one) Required
How many hours of sleep do you get per night? (Please check one) Required
What does your daily commute look like? Required
How many hours do you spend in front of a screen or digital device? Required
How many alcoholic beverages do you consume per week? (Please check one) Required
Which foods do you consume on a regular basis? Required
How often do you travel on a plane? Required
Do you exercise on a regular basis? Required
Do you smoke cigarettes, vape, or consume other tobacco products? Required

FEMALE CLIENTS ONLY

Are you taking oral contraceptives?
Are you pregnant or trying to become pregnant?
Are you undergoing any hormone replacement therapy treatments?
Any recent changes to or from your contraceptive treatments?
Are you experiencing any menopausal symptoms?

MALE CLIENTS ONLY

Do you experience irritation from shaving?
Do you experience ingrown hairs as a result of hair removal?

FUTURE APPOINTMENTS/CONTACT

May I call you at the provided phone number to confirm future appointments? Required
May I contact you via mail/email about future promotions and news? Required

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 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 the technician/esthetician/skin care professional from liability and assume full responsibility thereof

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