Facial Treatment Consultation Form

Treatment Required

Classic facial Deep cleansing facial Anti-aging facial Dermaplaning Chemical peel Facial massage

Today's Date

Name

Nombre

Apellido

Date of Birth

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Phone Number

E-mail

Emergency Contact Name

Nombre

Apellido

Phone Number

How did you hear about me?

If Other, please let me know

What are your skin care goals?

What are your skin care challenges?

Please feel free to go into more detail

Have you ever had a facial or skin treatment before?

Yes No Not sure

If Yes, when?

What Skin Care Products do you currently use?

Preferred Brand(s)

Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?

Yes, currently using Yes, used previously No

Please specify which product or type, if you answered 'Yes, currently using' to above.

Have you received any of these facial services in the last 30 days?

If yes, please confirm last date

Have you experienced any of these health conditions in the past or present?

If you checked yes to any of these please provide further information. If not mark N/A

Do you?

Smoke Drink alcohol Exercise regularly Follow a restricted diet

Do you take any dietary / health supplements?

Yes No Not sure

If yes, please list

Any known allergies (eg: aspirin, latex, nuts, essential oils)?

Yes No Not sure

If yes, please give details

Have you currently taking any prescription / over the counter medications

Yes No Not sure

If yes, please give details

Are you a smoker?

Yes No Occasionally

Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)

Yes No Not sure

Do you drink alcohol?

Yes No Occasionally

What is your daily water intake (glasses / litres)

Have you ever experienced claustrophobia?

Yes No Not sure

Please rate your stress level

Low Moderate High Very high

Hormonal health

Are you taking birth control?

Yes No Not sure

If yes, what kind

Are you pregnant or trying to become pregnant?

Pregnant Trying to become pregnant No

Any menopause issues?

Yes No Not applicable

If yes, please specify

Are you undergoing any hormone replacement therapy?

Yes No Not sure

If yes, please specify

Is there any other information you would like to make your therapist aware of? If yes, please give details:

After Facial Care Instructions: avoid direct sun exposure right after the treatment, including UV light and tanning beds, and apply broad-spectrum SPF 30+ if sun cannot be avoided. Facial massage, cupping and gua sha may cause temporary redness; cupping can leave marks that fade within days. In the evening, cleanse with a mild cleanser and use a non-active moisturizer; skip exfoliating products that day. Reach out with any concerns after your visit.

I have read the information I understand the terms I agree

Signature

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Facial Treatment Consultation Form

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