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Cosmetology Client Consultation Form

Gather a client's health history, skincare habits, and preferences ahead of a cosmetology appointment.

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In the Claude connectors directory

Name

First Name

Last Name

Age

Phone Number

Address

Street Address

City

State / Province

ZIP / Postal Code

Occupation

Please select the current health conditions present in your body

Diabetes High blood pressure Skin condition Heart condition None

Do you have any of the following conditions?

Pregnancy Recent surgery Epilepsy None

Do you have any allergies? If yes, please list them below

Have you undergone any surgical procedure? If yes, please list the name of the procedure and the reason

Are you currently taking any medications? If yes, please list them below including vitamins and supplements

Date of last menstrual period

Do you have children?

Yes No

Are you wearing contact lenses?

Yes No

Are you engaged in any sport? If yes, please share what sports you are currently practicing

How do you take care of your face?

How do you take care of your skin?

When was the last time you had professional cosmetic care?

How often do you go to a beauty salon?

Are you preparing for a special occasion?

Yes No

What type of event is this cosmetic care for?

Wedding Birthday Graduation Other

When is the event?

What time is the event?

Would you like a trial service?

Yes No

What date can we do the trial service?

Do you have any special instructions?

Would you like to receive promotions and offers via email?

Yes No

How did you hear about us?

Social media Friend or family referral Search engine Other

I confirm that the information provided in this form is true and accurate to the best of my knowledge

Client's Signature

Sign here

Date Signed

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