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Client Consultation Form-Skin

Client Consultation Form-Skin


First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Client Consultation-Skin
Have you ever had a facial treatment before?*
No
Yes
Which of the following best describe 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? *
No
Yes

If yes, please specify:
Have you ever had a chemical peels, laser treatments, or microdermabrasion? *
No
Yes

If yes, please specify when?
Do you use Accutaine, Retin-A, Renova, Adapalene Hydroxyl Acid or any other Retinol/Vitamin A derivative products?*
No
Yes

If yes, please specify what and when last used:
Have you used acne medication?*
No
Yes

If yes, when and which medication?
Have you experienced Botox, Restylane, or collagen injections?*
No
Yes

If yes, please specify:

What skin care products are you currently using? (List brands if known)
What areas of concerns do you have regarding your: Skin (check all that apply)
Breakouts/acne
Sun damage
Rosacea
Flaky skin
Sun/liver/brown spots
Uneven skin tone
Excessive oil/shine
Dull/dry skin
Redness/ruddiness
Blackheads/whiteheads
Wrinkles/fine lines
Broken capillaries
Dehydrated
Eyes (check all that apply)*
Dehydrated
Dark circles
Wrinkles
Puffiness
Lips (check all that apply)*
Dehydrated
Cracked/chapped lips
Have you ever had an allergic reaction to any of the following (check all that apply)*
Cosmetics
Fragrance
Animals
Drugs
AHAs
Food
Latex
Iodine
Medication
Shellfish
Sunscreens
Pollen
Do you currently use SPF on your face?*
No
Yes
Have you had any recent tanning bed or sun exposure that changed the color of your skin? *
No
Yes

If yes, please specify:
How many glasses of water do you drink per day? (please check one)
1-3 glasses
4-7 glasses
8+ glasses
How many caffeinated beverages (coffee, tea, soda, etc.) do you consume per day? (please check one)
None
1-2 drinks
3-5 drinks
6+ drinks
How many alcoholic beverages do you consume per week? (please check one)
I don't drink
1-3 drinks
4-7 drinks
8+ drinks
How many hours if sleep do you get per night? (Please check one)
3-5 hours
6-8 hours
8-10 hours
10+ hours
Which foods do you consume on a regular basis?
Fruits
Vegetables
Dairy/Eggs
Cheese
Poultry
Fish
Grains/Bread
Processed Sugar
Processed Meats
What does your daily commute look like?
Car
Bike
Public Transport
Walk
I don't commute
How many hours do you spend in front of a screen or digital device?*
<3 hours
4-6 hours
7-9 hours
10-12 hours
12+ hours
Do you exercise on a regular basis?*
No
Yes
Do you smoke cigarettes, vape, or consume other tobacco products?*
No
Yes
FEMALE CLIENTS: Are you taking oral contraceptives?*
No
Yes
N/A

If yes, please specify:
FEMALE CLIENTS: Any recent changes to or from your contraceptive treatments?*
No
Yes
N/A

If yes, please specify:
FEMALE CLIENTS: Are you pregnant or trying to become pregnant?*
No
Yes
N/A
FEMALE CLIENTS: Are you experiencing any menopausal symptoms?*
No
Yes
N/A

If yes please specify:
FEMALE CLIENTS: Are you undergoing any hormone replacement therapy treatments?*
No
Yes
N/A

If yes, please specify:
MALE CLIENTS: Do you experience irritation from shaving?*
No
Yes
N/A

If yes, please specify:
MALE CLIENTS: Do you experience ingrown hairs as a result of hair removal?*
No
Yes
N/A
May I call you at the provided phone number to confirm future appointments?*
No
Yes
May I contact you via mail/email about future promotions and news?*
No
Yes

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that its 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. 

First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Client Consultation-Skin
Have you ever had a facial treatment before?*
No
Yes
Which of the following best describe 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? *
No
Yes

If yes, please specify:
Have you ever had a chemical peels, laser treatments, or microdermabrasion? *
No
Yes

If yes, please specify when?
Do you use Accutaine, Retin-A, Renova, Adapalene Hydroxyl Acid or any other Retinol/Vitamin A derivative products?*
No
Yes

If yes, please specify what and when last used:
Have you used acne medication?*
No
Yes

If yes, when and which medication?
Have you experienced Botox, Restylane, or collagen injections?*
No
Yes

If yes, please specify:

What skin care products are you currently using? (List brands if known)
What areas of concerns do you have regarding your: Skin (check all that apply)
Breakouts/acne
Sun damage
Rosacea
Flaky skin
Sun/liver/brown spots
Uneven skin tone
Excessive oil/shine
Dull/dry skin
Redness/ruddiness
Blackheads/whiteheads
Wrinkles/fine lines
Broken capillaries
Dehydrated
Eyes (check all that apply)*
Dehydrated
Dark circles
Wrinkles
Puffiness
Lips (check all that apply)*
Dehydrated
Cracked/chapped lips
Have you ever had an allergic reaction to any of the following (check all that apply)*
Cosmetics
Fragrance
Animals
Drugs
AHAs
Food
Latex
Iodine
Medication
Shellfish
Sunscreens
Pollen
Do you currently use SPF on your face?*
No
Yes
Have you had any recent tanning bed or sun exposure that changed the color of your skin? *
No
Yes

If yes, please specify:
How many glasses of water do you drink per day? (please check one)
1-3 glasses
4-7 glasses
8+ glasses
How many caffeinated beverages (coffee, tea, soda, etc.) do you consume per day? (please check one)
None
1-2 drinks
3-5 drinks
6+ drinks
How many alcoholic beverages do you consume per week? (please check one)
I don't drink
1-3 drinks
4-7 drinks
8+ drinks
How many hours if sleep do you get per night? (Please check one)
3-5 hours
6-8 hours
8-10 hours
10+ hours
Which foods do you consume on a regular basis?
Fruits
Vegetables
Dairy/Eggs
Cheese
Poultry
Fish
Grains/Bread
Processed Sugar
Processed Meats
What does your daily commute look like?
Car
Bike
Public Transport
Walk
I don't commute
How many hours do you spend in front of a screen or digital device?*
<3 hours
4-6 hours
7-9 hours
10-12 hours
12+ hours
Do you exercise on a regular basis?*
No
Yes
Do you smoke cigarettes, vape, or consume other tobacco products?*
No
Yes
FEMALE CLIENTS: Are you taking oral contraceptives?*
No
Yes
N/A

If yes, please specify:
FEMALE CLIENTS: Any recent changes to or from your contraceptive treatments?*
No
Yes
N/A

If yes, please specify:
FEMALE CLIENTS: Are you pregnant or trying to become pregnant?*
No
Yes
N/A
FEMALE CLIENTS: Are you experiencing any menopausal symptoms?*
No
Yes
N/A

If yes please specify:
FEMALE CLIENTS: Are you undergoing any hormone replacement therapy treatments?*
No
Yes
N/A

If yes, please specify:
MALE CLIENTS: Do you experience irritation from shaving?*
No
Yes
N/A

If yes, please specify:
MALE CLIENTS: Do you experience ingrown hairs as a result of hair removal?*
No
Yes
N/A
May I call you at the provided phone number to confirm future appointments?*
No
Yes
May I contact you via mail/email about future promotions and news?*
No
Yes

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that its 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. 

Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Client Consultation-Skin
Have you ever had a facial treatment before?*
No
Yes
Which of the following best describe 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? *
No
Yes

If yes, please specify:
Have you ever had a chemical peels, laser treatments, or microdermabrasion? *
No
Yes

If yes, please specify when?
Do you use Accutaine, Retin-A, Renova, Adapalene Hydroxyl Acid or any other Retinol/Vitamin A derivative products?*
No
Yes

If yes, please specify what and when last used:
Have you used acne medication?*
No
Yes

If yes, when and which medication?
Have you experienced Botox, Restylane, or collagen injections?*
No
Yes

If yes, please specify:

What skin care products are you currently using? (List brands if known)
What areas of concerns do you have regarding your: Skin (check all that apply)
Breakouts/acne
Sun damage
Rosacea
Flaky skin
Sun/liver/brown spots
Uneven skin tone
Excessive oil/shine
Dull/dry skin
Redness/ruddiness
Blackheads/whiteheads
Wrinkles/fine lines
Broken capillaries
Dehydrated
Eyes (check all that apply)*
Dehydrated
Dark circles
Wrinkles
Puffiness
Lips (check all that apply)*
Dehydrated
Cracked/chapped lips
Have you ever had an allergic reaction to any of the following (check all that apply)*
Cosmetics
Fragrance
Animals
Drugs
AHAs
Food
Latex
Iodine
Medication
Shellfish
Sunscreens
Pollen
Do you currently use SPF on your face?*
No
Yes
Have you had any recent tanning bed or sun exposure that changed the color of your skin? *
No
Yes

If yes, please specify:
How many glasses of water do you drink per day? (please check one)
1-3 glasses
4-7 glasses
8+ glasses
How many caffeinated beverages (coffee, tea, soda, etc.) do you consume per day? (please check one)
None
1-2 drinks
3-5 drinks
6+ drinks
How many alcoholic beverages do you consume per week? (please check one)
I don't drink
1-3 drinks
4-7 drinks
8+ drinks
How many hours if sleep do you get per night? (Please check one)
3-5 hours
6-8 hours
8-10 hours
10+ hours
Which foods do you consume on a regular basis?
Fruits
Vegetables
Dairy/Eggs
Cheese
Poultry
Fish
Grains/Bread
Processed Sugar
Processed Meats
What does your daily commute look like?
Car
Bike
Public Transport
Walk
I don't commute
How many hours do you spend in front of a screen or digital device?*
<3 hours
4-6 hours
7-9 hours
10-12 hours
12+ hours
Do you exercise on a regular basis?*
No
Yes
Do you smoke cigarettes, vape, or consume other tobacco products?*
No
Yes
FEMALE CLIENTS: Are you taking oral contraceptives?*
No
Yes
N/A

If yes, please specify:
FEMALE CLIENTS: Any recent changes to or from your contraceptive treatments?*
No
Yes
N/A

If yes, please specify:
FEMALE CLIENTS: Are you pregnant or trying to become pregnant?*
No
Yes
N/A
FEMALE CLIENTS: Are you experiencing any menopausal symptoms?*
No
Yes
N/A

If yes please specify:
FEMALE CLIENTS: Are you undergoing any hormone replacement therapy treatments?*
No
Yes
N/A

If yes, please specify:
MALE CLIENTS: Do you experience irritation from shaving?*
No
Yes
N/A

If yes, please specify:
MALE CLIENTS: Do you experience ingrown hairs as a result of hair removal?*
No
Yes
N/A
May I call you at the provided phone number to confirm future appointments?*
No
Yes
May I contact you via mail/email about future promotions and news?*
No
Yes

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that its 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. 

Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Client Consultation-Skin
Have you ever had a facial treatment before?*
No
Yes
Which of the following best describe 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? *
No
Yes

If yes, please specify:
Have you ever had a chemical peels, laser treatments, or microdermabrasion? *
No
Yes

If yes, please specify when?
Do you use Accutaine, Retin-A, Renova, Adapalene Hydroxyl Acid or any other Retinol/Vitamin A derivative products?*
No
Yes

If yes, please specify what and when last used:
Have you used acne medication?*
No
Yes

If yes, when and which medication?
Have you experienced Botox, Restylane, or collagen injections?*
No
Yes

If yes, please specify:

What skin care products are you currently using? (List brands if known)
What areas of concerns do you have regarding your: Skin (check all that apply)
Breakouts/acne
Sun damage
Rosacea
Flaky skin
Sun/liver/brown spots
Uneven skin tone
Excessive oil/shine
Dull/dry skin
Redness/ruddiness
Blackheads/whiteheads
Wrinkles/fine lines
Broken capillaries
Dehydrated
Eyes (check all that apply)*
Dehydrated
Dark circles
Wrinkles
Puffiness
Lips (check all that apply)*
Dehydrated
Cracked/chapped lips
Have you ever had an allergic reaction to any of the following (check all that apply)*
Cosmetics
Fragrance
Animals
Drugs
AHAs
Food
Latex
Iodine
Medication
Shellfish
Sunscreens
Pollen
Do you currently use SPF on your face?*
No
Yes
Have you had any recent tanning bed or sun exposure that changed the color of your skin? *
No
Yes

If yes, please specify:
How many glasses of water do you drink per day? (please check one)
1-3 glasses
4-7 glasses
8+ glasses
How many caffeinated beverages (coffee, tea, soda, etc.) do you consume per day? (please check one)
None
1-2 drinks
3-5 drinks
6+ drinks
How many alcoholic beverages do you consume per week? (please check one)
I don't drink
1-3 drinks
4-7 drinks
8+ drinks
How many hours if sleep do you get per night? (Please check one)
3-5 hours
6-8 hours
8-10 hours
10+ hours
Which foods do you consume on a regular basis?
Fruits
Vegetables
Dairy/Eggs
Cheese
Poultry
Fish
Grains/Bread
Processed Sugar
Processed Meats
What does your daily commute look like?
Car
Bike
Public Transport
Walk
I don't commute
How many hours do you spend in front of a screen or digital device?*
<3 hours
4-6 hours
7-9 hours
10-12 hours
12+ hours
Do you exercise on a regular basis?*
No
Yes
Do you smoke cigarettes, vape, or consume other tobacco products?*
No
Yes
FEMALE CLIENTS: Are you taking oral contraceptives?*
No
Yes
N/A

If yes, please specify:
FEMALE CLIENTS: Any recent changes to or from your contraceptive treatments?*
No
Yes
N/A

If yes, please specify:
FEMALE CLIENTS: Are you pregnant or trying to become pregnant?*
No
Yes
N/A
FEMALE CLIENTS: Are you experiencing any menopausal symptoms?*
No
Yes
N/A

If yes please specify:
FEMALE CLIENTS: Are you undergoing any hormone replacement therapy treatments?*
No
Yes
N/A

If yes, please specify:
MALE CLIENTS: Do you experience irritation from shaving?*
No
Yes
N/A

If yes, please specify:
MALE CLIENTS: Do you experience ingrown hairs as a result of hair removal?*
No
Yes
N/A
May I call you at the provided phone number to confirm future appointments?*
No
Yes
May I contact you via mail/email about future promotions and news?*
No
Yes

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that its 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. 

Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Client Consultation-Skin
Have you ever had a facial treatment before?*
No
Yes
Which of the following best describe 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? *
No
Yes

If yes, please specify:
Have you ever had a chemical peels, laser treatments, or microdermabrasion? *
No
Yes

If yes, please specify when?
Do you use Accutaine, Retin-A, Renova, Adapalene Hydroxyl Acid or any other Retinol/Vitamin A derivative products?*
No
Yes

If yes, please specify what and when last used:
Have you used acne medication?*
No
Yes

If yes, when and which medication?
Have you experienced Botox, Restylane, or collagen injections?*
No
Yes

If yes, please specify:

What skin care products are you currently using? (List brands if known)
What areas of concerns do you have regarding your: Skin (check all that apply)
Breakouts/acne
Sun damage
Rosacea
Flaky skin
Sun/liver/brown spots
Uneven skin tone
Excessive oil/shine
Dull/dry skin
Redness/ruddiness
Blackheads/whiteheads
Wrinkles/fine lines
Broken capillaries
Dehydrated
Eyes (check all that apply)*
Dehydrated
Dark circles
Wrinkles
Puffiness
Lips (check all that apply)*
Dehydrated
Cracked/chapped lips
Have you ever had an allergic reaction to any of the following (check all that apply)*
Cosmetics
Fragrance
Animals
Drugs
AHAs
Food
Latex
Iodine
Medication
Shellfish
Sunscreens
Pollen
Do you currently use SPF on your face?*
No
Yes
Have you had any recent tanning bed or sun exposure that changed the color of your skin? *
No
Yes

If yes, please specify:
How many glasses of water do you drink per day? (please check one)
1-3 glasses
4-7 glasses
8+ glasses
How many caffeinated beverages (coffee, tea, soda, etc.) do you consume per day? (please check one)
None
1-2 drinks
3-5 drinks
6+ drinks
How many alcoholic beverages do you consume per week? (please check one)
I don't drink
1-3 drinks
4-7 drinks
8+ drinks
How many hours if sleep do you get per night? (Please check one)
3-5 hours
6-8 hours
8-10 hours
10+ hours
Which foods do you consume on a regular basis?
Fruits
Vegetables
Dairy/Eggs
Cheese
Poultry
Fish
Grains/Bread
Processed Sugar
Processed Meats
What does your daily commute look like?
Car
Bike
Public Transport
Walk
I don't commute
How many hours do you spend in front of a screen or digital device?*
<3 hours
4-6 hours
7-9 hours
10-12 hours
12+ hours
Do you exercise on a regular basis?*
No
Yes
Do you smoke cigarettes, vape, or consume other tobacco products?*
No
Yes
FEMALE CLIENTS: Are you taking oral contraceptives?*
No
Yes
N/A

If yes, please specify:
FEMALE CLIENTS: Any recent changes to or from your contraceptive treatments?*
No
Yes
N/A

If yes, please specify:
FEMALE CLIENTS: Are you pregnant or trying to become pregnant?*
No
Yes
N/A
FEMALE CLIENTS: Are you experiencing any menopausal symptoms?*
No
Yes
N/A

If yes please specify:
FEMALE CLIENTS: Are you undergoing any hormone replacement therapy treatments?*
No
Yes
N/A

If yes, please specify:
MALE CLIENTS: Do you experience irritation from shaving?*
No
Yes
N/A

If yes, please specify:
MALE CLIENTS: Do you experience ingrown hairs as a result of hair removal?*
No
Yes
N/A
May I call you at the provided phone number to confirm future appointments?*
No
Yes
May I contact you via mail/email about future promotions and news?*
No
Yes

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that its 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. 

Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Client Consultation-Skin
Have you ever had a facial treatment before?*
No
Yes
Which of the following best describe 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? *
No
Yes

If yes, please specify:
Have you ever had a chemical peels, laser treatments, or microdermabrasion? *
No
Yes

If yes, please specify when?
Do you use Accutaine, Retin-A, Renova, Adapalene Hydroxyl Acid or any other Retinol/Vitamin A derivative products?*
No
Yes

If yes, please specify what and when last used:
Have you used acne medication?*
No
Yes

If yes, when and which medication?
Have you experienced Botox, Restylane, or collagen injections?*
No
Yes

If yes, please specify:

What skin care products are you currently using? (List brands if known)
What areas of concerns do you have regarding your: Skin (check all that apply)
Breakouts/acne
Sun damage
Rosacea
Flaky skin
Sun/liver/brown spots
Uneven skin tone
Excessive oil/shine
Dull/dry skin
Redness/ruddiness
Blackheads/whiteheads
Wrinkles/fine lines
Broken capillaries
Dehydrated
Eyes (check all that apply)*
Dehydrated
Dark circles
Wrinkles
Puffiness
Lips (check all that apply)*
Dehydrated
Cracked/chapped lips
Have you ever had an allergic reaction to any of the following (check all that apply)*
Cosmetics
Fragrance
Animals
Drugs
AHAs
Food
Latex
Iodine
Medication
Shellfish
Sunscreens
Pollen
Do you currently use SPF on your face?*
No
Yes
Have you had any recent tanning bed or sun exposure that changed the color of your skin? *
No
Yes

If yes, please specify:
How many glasses of water do you drink per day? (please check one)
1-3 glasses
4-7 glasses
8+ glasses
How many caffeinated beverages (coffee, tea, soda, etc.) do you consume per day? (please check one)
None
1-2 drinks
3-5 drinks
6+ drinks
How many alcoholic beverages do you consume per week? (please check one)
I don't drink
1-3 drinks
4-7 drinks
8+ drinks
How many hours if sleep do you get per night? (Please check one)
3-5 hours
6-8 hours
8-10 hours
10+ hours
Which foods do you consume on a regular basis?
Fruits
Vegetables
Dairy/Eggs
Cheese
Poultry
Fish
Grains/Bread
Processed Sugar
Processed Meats
What does your daily commute look like?
Car
Bike
Public Transport
Walk
I don't commute
How many hours do you spend in front of a screen or digital device?*
<3 hours
4-6 hours
7-9 hours
10-12 hours
12+ hours
Do you exercise on a regular basis?*
No
Yes
Do you smoke cigarettes, vape, or consume other tobacco products?*
No
Yes
FEMALE CLIENTS: Are you taking oral contraceptives?*
No
Yes
N/A

If yes, please specify:
FEMALE CLIENTS: Any recent changes to or from your contraceptive treatments?*
No
Yes
N/A

If yes, please specify:
FEMALE CLIENTS: Are you pregnant or trying to become pregnant?*
No
Yes
N/A
FEMALE CLIENTS: Are you experiencing any menopausal symptoms?*
No
Yes
N/A

If yes please specify:
FEMALE CLIENTS: Are you undergoing any hormone replacement therapy treatments?*
No
Yes
N/A

If yes, please specify:
MALE CLIENTS: Do you experience irritation from shaving?*
No
Yes
N/A

If yes, please specify:
MALE CLIENTS: Do you experience ingrown hairs as a result of hair removal?*
No
Yes
N/A
May I call you at the provided phone number to confirm future appointments?*
No
Yes
May I contact you via mail/email about future promotions and news?*
No
Yes

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that its 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. 

Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Client Consultation-Skin
Have you ever had a facial treatment before?*
No
Yes
Which of the following best describe 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? *
No
Yes

If yes, please specify:
Have you ever had a chemical peels, laser treatments, or microdermabrasion? *
No
Yes

If yes, please specify when?
Do you use Accutaine, Retin-A, Renova, Adapalene Hydroxyl Acid or any other Retinol/Vitamin A derivative products?*
No
Yes

If yes, please specify what and when last used:
Have you used acne medication?*
No
Yes

If yes, when and which medication?
Have you experienced Botox, Restylane, or collagen injections?*
No
Yes

If yes, please specify:

What skin care products are you currently using? (List brands if known)
What areas of concerns do you have regarding your: Skin (check all that apply)
Breakouts/acne
Sun damage
Rosacea
Flaky skin
Sun/liver/brown spots
Uneven skin tone
Excessive oil/shine
Dull/dry skin
Redness/ruddiness
Blackheads/whiteheads
Wrinkles/fine lines
Broken capillaries
Dehydrated
Eyes (check all that apply)*
Dehydrated
Dark circles
Wrinkles
Puffiness
Lips (check all that apply)*
Dehydrated
Cracked/chapped lips
Have you ever had an allergic reaction to any of the following (check all that apply)*
Cosmetics
Fragrance
Animals
Drugs
AHAs
Food
Latex
Iodine
Medication
Shellfish
Sunscreens
Pollen
Do you currently use SPF on your face?*
No
Yes
Have you had any recent tanning bed or sun exposure that changed the color of your skin? *
No
Yes

If yes, please specify:
How many glasses of water do you drink per day? (please check one)
1-3 glasses
4-7 glasses
8+ glasses
How many caffeinated beverages (coffee, tea, soda, etc.) do you consume per day? (please check one)
None
1-2 drinks
3-5 drinks
6+ drinks
How many alcoholic beverages do you consume per week? (please check one)
I don't drink
1-3 drinks
4-7 drinks
8+ drinks
How many hours if sleep do you get per night? (Please check one)
3-5 hours
6-8 hours
8-10 hours
10+ hours
Which foods do you consume on a regular basis?
Fruits
Vegetables
Dairy/Eggs
Cheese
Poultry
Fish
Grains/Bread
Processed Sugar
Processed Meats
What does your daily commute look like?
Car
Bike
Public Transport
Walk
I don't commute
How many hours do you spend in front of a screen or digital device?*
<3 hours
4-6 hours
7-9 hours
10-12 hours
12+ hours
Do you exercise on a regular basis?*
No
Yes
Do you smoke cigarettes, vape, or consume other tobacco products?*
No
Yes
FEMALE CLIENTS: Are you taking oral contraceptives?*
No
Yes
N/A

If yes, please specify:
FEMALE CLIENTS: Any recent changes to or from your contraceptive treatments?*
No
Yes
N/A

If yes, please specify:
FEMALE CLIENTS: Are you pregnant or trying to become pregnant?*
No
Yes
N/A
FEMALE CLIENTS: Are you experiencing any menopausal symptoms?*
No
Yes
N/A

If yes please specify:
FEMALE CLIENTS: Are you undergoing any hormone replacement therapy treatments?*
No
Yes
N/A

If yes, please specify:
MALE CLIENTS: Do you experience irritation from shaving?*
No
Yes
N/A

If yes, please specify:
MALE CLIENTS: Do you experience ingrown hairs as a result of hair removal?*
No
Yes
N/A
May I call you at the provided phone number to confirm future appointments?*
No
Yes
May I contact you via mail/email about future promotions and news?*
No
Yes

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that its 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. 

Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Client Consultation-Skin
Have you ever had a facial treatment before?*
No
Yes
Which of the following best describe 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? *
No
Yes

If yes, please specify:
Have you ever had a chemical peels, laser treatments, or microdermabrasion? *
No
Yes

If yes, please specify when?
Do you use Accutaine, Retin-A, Renova, Adapalene Hydroxyl Acid or any other Retinol/Vitamin A derivative products?*
No
Yes

If yes, please specify what and when last used:
Have you used acne medication?*
No
Yes

If yes, when and which medication?
Have you experienced Botox, Restylane, or collagen injections?*
No
Yes

If yes, please specify:

What skin care products are you currently using? (List brands if known)
What areas of concerns do you have regarding your: Skin (check all that apply)
Breakouts/acne
Sun damage
Rosacea
Flaky skin
Sun/liver/brown spots
Uneven skin tone
Excessive oil/shine
Dull/dry skin
Redness/ruddiness
Blackheads/whiteheads
Wrinkles/fine lines
Broken capillaries
Dehydrated
Eyes (check all that apply)*
Dehydrated
Dark circles
Wrinkles
Puffiness
Lips (check all that apply)*
Dehydrated
Cracked/chapped lips
Have you ever had an allergic reaction to any of the following (check all that apply)*
Cosmetics
Fragrance
Animals
Drugs
AHAs
Food
Latex
Iodine
Medication
Shellfish
Sunscreens
Pollen
Do you currently use SPF on your face?*
No
Yes
Have you had any recent tanning bed or sun exposure that changed the color of your skin? *
No
Yes

If yes, please specify:
How many glasses of water do you drink per day? (please check one)
1-3 glasses
4-7 glasses
8+ glasses
How many caffeinated beverages (coffee, tea, soda, etc.) do you consume per day? (please check one)
None
1-2 drinks
3-5 drinks
6+ drinks
How many alcoholic beverages do you consume per week? (please check one)
I don't drink
1-3 drinks
4-7 drinks
8+ drinks
How many hours if sleep do you get per night? (Please check one)
3-5 hours
6-8 hours
8-10 hours
10+ hours
Which foods do you consume on a regular basis?
Fruits
Vegetables
Dairy/Eggs
Cheese
Poultry
Fish
Grains/Bread
Processed Sugar
Processed Meats
What does your daily commute look like?
Car
Bike
Public Transport
Walk
I don't commute
How many hours do you spend in front of a screen or digital device?*
<3 hours
4-6 hours
7-9 hours
10-12 hours
12+ hours
Do you exercise on a regular basis?*
No
Yes
Do you smoke cigarettes, vape, or consume other tobacco products?*
No
Yes
FEMALE CLIENTS: Are you taking oral contraceptives?*
No
Yes
N/A

If yes, please specify:
FEMALE CLIENTS: Any recent changes to or from your contraceptive treatments?*
No
Yes
N/A

If yes, please specify:
FEMALE CLIENTS: Are you pregnant or trying to become pregnant?*
No
Yes
N/A
FEMALE CLIENTS: Are you experiencing any menopausal symptoms?*
No
Yes
N/A

If yes please specify:
FEMALE CLIENTS: Are you undergoing any hormone replacement therapy treatments?*
No
Yes
N/A

If yes, please specify:
MALE CLIENTS: Do you experience irritation from shaving?*
No
Yes
N/A

If yes, please specify:
MALE CLIENTS: Do you experience ingrown hairs as a result of hair removal?*
No
Yes
N/A
May I call you at the provided phone number to confirm future appointments?*
No
Yes
May I contact you via mail/email about future promotions and news?*
No
Yes

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that its 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. 

Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Client Consultation-Skin
Have you ever had a facial treatment before?*
No
Yes
Which of the following best describe 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? *
No
Yes

If yes, please specify:
Have you ever had a chemical peels, laser treatments, or microdermabrasion? *
No
Yes

If yes, please specify when?
Do you use Accutaine, Retin-A, Renova, Adapalene Hydroxyl Acid or any other Retinol/Vitamin A derivative products?*
No
Yes

If yes, please specify what and when last used:
Have you used acne medication?*
No
Yes

If yes, when and which medication?
Have you experienced Botox, Restylane, or collagen injections?*
No
Yes

If yes, please specify:

What skin care products are you currently using? (List brands if known)
What areas of concerns do you have regarding your: Skin (check all that apply)
Breakouts/acne
Sun damage
Rosacea
Flaky skin
Sun/liver/brown spots
Uneven skin tone
Excessive oil/shine
Dull/dry skin
Redness/ruddiness
Blackheads/whiteheads
Wrinkles/fine lines
Broken capillaries
Dehydrated
Eyes (check all that apply)*
Dehydrated
Dark circles
Wrinkles
Puffiness
Lips (check all that apply)*
Dehydrated
Cracked/chapped lips
Have you ever had an allergic reaction to any of the following (check all that apply)*
Cosmetics
Fragrance
Animals
Drugs
AHAs
Food
Latex
Iodine
Medication
Shellfish
Sunscreens
Pollen
Do you currently use SPF on your face?*
No
Yes
Have you had any recent tanning bed or sun exposure that changed the color of your skin? *
No
Yes

If yes, please specify:
How many glasses of water do you drink per day? (please check one)
1-3 glasses
4-7 glasses
8+ glasses
How many caffeinated beverages (coffee, tea, soda, etc.) do you consume per day? (please check one)
None
1-2 drinks
3-5 drinks
6+ drinks
How many alcoholic beverages do you consume per week? (please check one)
I don't drink
1-3 drinks
4-7 drinks
8+ drinks
How many hours if sleep do you get per night? (Please check one)
3-5 hours
6-8 hours
8-10 hours
10+ hours
Which foods do you consume on a regular basis?
Fruits
Vegetables
Dairy/Eggs
Cheese
Poultry
Fish
Grains/Bread
Processed Sugar
Processed Meats
What does your daily commute look like?
Car
Bike
Public Transport
Walk
I don't commute
How many hours do you spend in front of a screen or digital device?*
<3 hours
4-6 hours
7-9 hours
10-12 hours
12+ hours
Do you exercise on a regular basis?*
No
Yes
Do you smoke cigarettes, vape, or consume other tobacco products?*
No
Yes
FEMALE CLIENTS: Are you taking oral contraceptives?*
No
Yes
N/A

If yes, please specify:
FEMALE CLIENTS: Any recent changes to or from your contraceptive treatments?*
No
Yes
N/A

If yes, please specify:
FEMALE CLIENTS: Are you pregnant or trying to become pregnant?*
No
Yes
N/A
FEMALE CLIENTS: Are you experiencing any menopausal symptoms?*
No
Yes
N/A

If yes please specify:
FEMALE CLIENTS: Are you undergoing any hormone replacement therapy treatments?*
No
Yes
N/A

If yes, please specify:
MALE CLIENTS: Do you experience irritation from shaving?*
No
Yes
N/A

If yes, please specify:
MALE CLIENTS: Do you experience ingrown hairs as a result of hair removal?*
No
Yes
N/A
May I call you at the provided phone number to confirm future appointments?*
No
Yes
May I contact you via mail/email about future promotions and news?*
No
Yes

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that its 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. 

Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Client Consultation-Skin
Have you ever had a facial treatment before?*
No
Yes
Which of the following best describe 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? *
No
Yes

If yes, please specify:
Have you ever had a chemical peels, laser treatments, or microdermabrasion? *
No
Yes

If yes, please specify when?
Do you use Accutaine, Retin-A, Renova, Adapalene Hydroxyl Acid or any other Retinol/Vitamin A derivative products?*
No
Yes

If yes, please specify what and when last used:
Have you used acne medication?*
No
Yes

If yes, when and which medication?
Have you experienced Botox, Restylane, or collagen injections?*
No
Yes

If yes, please specify:

What skin care products are you currently using? (List brands if known)
What areas of concerns do you have regarding your: Skin (check all that apply)
Breakouts/acne
Sun damage
Rosacea
Flaky skin
Sun/liver/brown spots
Uneven skin tone
Excessive oil/shine
Dull/dry skin
Redness/ruddiness
Blackheads/whiteheads
Wrinkles/fine lines
Broken capillaries
Dehydrated
Eyes (check all that apply)*
Dehydrated
Dark circles
Wrinkles
Puffiness
Lips (check all that apply)*
Dehydrated
Cracked/chapped lips
Have you ever had an allergic reaction to any of the following (check all that apply)*
Cosmetics
Fragrance
Animals
Drugs
AHAs
Food
Latex
Iodine
Medication
Shellfish
Sunscreens
Pollen
Do you currently use SPF on your face?*
No
Yes
Have you had any recent tanning bed or sun exposure that changed the color of your skin? *
No
Yes

If yes, please specify:
How many glasses of water do you drink per day? (please check one)
1-3 glasses
4-7 glasses
8+ glasses
How many caffeinated beverages (coffee, tea, soda, etc.) do you consume per day? (please check one)
None
1-2 drinks
3-5 drinks
6+ drinks
How many alcoholic beverages do you consume per week? (please check one)
I don't drink
1-3 drinks
4-7 drinks
8+ drinks
How many hours if sleep do you get per night? (Please check one)
3-5 hours
6-8 hours
8-10 hours
10+ hours
Which foods do you consume on a regular basis?
Fruits
Vegetables
Dairy/Eggs
Cheese
Poultry
Fish
Grains/Bread
Processed Sugar
Processed Meats
What does your daily commute look like?
Car
Bike
Public Transport
Walk
I don't commute
How many hours do you spend in front of a screen or digital device?*
<3 hours
4-6 hours
7-9 hours
10-12 hours
12+ hours
Do you exercise on a regular basis?*
No
Yes
Do you smoke cigarettes, vape, or consume other tobacco products?*
No
Yes
FEMALE CLIENTS: Are you taking oral contraceptives?*
No
Yes
N/A

If yes, please specify:
FEMALE CLIENTS: Any recent changes to or from your contraceptive treatments?*
No
Yes
N/A

If yes, please specify:
FEMALE CLIENTS: Are you pregnant or trying to become pregnant?*
No
Yes
N/A
FEMALE CLIENTS: Are you experiencing any menopausal symptoms?*
No
Yes
N/A

If yes please specify:
FEMALE CLIENTS: Are you undergoing any hormone replacement therapy treatments?*
No
Yes
N/A

If yes, please specify:
MALE CLIENTS: Do you experience irritation from shaving?*
No
Yes
N/A

If yes, please specify:
MALE CLIENTS: Do you experience ingrown hairs as a result of hair removal?*
No
Yes
N/A
May I call you at the provided phone number to confirm future appointments?*
No
Yes
May I contact you via mail/email about future promotions and news?*
No
Yes

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that its 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. 

Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Client Consultation-Skin
Have you ever had a facial treatment before?*
No
Yes
Which of the following best describe 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? *
No
Yes

If yes, please specify:
Have you ever had a chemical peels, laser treatments, or microdermabrasion? *
No
Yes

If yes, please specify when?
Do you use Accutaine, Retin-A, Renova, Adapalene Hydroxyl Acid or any other Retinol/Vitamin A derivative products?*
No
Yes

If yes, please specify what and when last used:
Have you used acne medication?*
No
Yes

If yes, when and which medication?
Have you experienced Botox, Restylane, or collagen injections?*
No
Yes

If yes, please specify:

What skin care products are you currently using? (List brands if known)
What areas of concerns do you have regarding your: Skin (check all that apply)
Breakouts/acne
Sun damage
Rosacea
Flaky skin
Sun/liver/brown spots
Uneven skin tone
Excessive oil/shine
Dull/dry skin
Redness/ruddiness
Blackheads/whiteheads
Wrinkles/fine lines
Broken capillaries
Dehydrated
Eyes (check all that apply)*
Dehydrated
Dark circles
Wrinkles
Puffiness
Lips (check all that apply)*
Dehydrated
Cracked/chapped lips
Have you ever had an allergic reaction to any of the following (check all that apply)*
Cosmetics
Fragrance
Animals
Drugs
AHAs
Food
Latex
Iodine
Medication
Shellfish
Sunscreens
Pollen
Do you currently use SPF on your face?*
No
Yes
Have you had any recent tanning bed or sun exposure that changed the color of your skin? *
No
Yes

If yes, please specify:
How many glasses of water do you drink per day? (please check one)
1-3 glasses
4-7 glasses
8+ glasses
How many caffeinated beverages (coffee, tea, soda, etc.) do you consume per day? (please check one)
None
1-2 drinks
3-5 drinks
6+ drinks
How many alcoholic beverages do you consume per week? (please check one)
I don't drink
1-3 drinks
4-7 drinks
8+ drinks
How many hours if sleep do you get per night? (Please check one)
3-5 hours
6-8 hours
8-10 hours
10+ hours
Which foods do you consume on a regular basis?
Fruits
Vegetables
Dairy/Eggs
Cheese
Poultry
Fish
Grains/Bread
Processed Sugar
Processed Meats
What does your daily commute look like?
Car
Bike
Public Transport
Walk
I don't commute
How many hours do you spend in front of a screen or digital device?*
<3 hours
4-6 hours
7-9 hours
10-12 hours
12+ hours
Do you exercise on a regular basis?*
No
Yes
Do you smoke cigarettes, vape, or consume other tobacco products?*
No
Yes
FEMALE CLIENTS: Are you taking oral contraceptives?*
No
Yes
N/A

If yes, please specify:
FEMALE CLIENTS: Any recent changes to or from your contraceptive treatments?*
No
Yes
N/A

If yes, please specify:
FEMALE CLIENTS: Are you pregnant or trying to become pregnant?*
No
Yes
N/A
FEMALE CLIENTS: Are you experiencing any menopausal symptoms?*
No
Yes
N/A

If yes please specify:
FEMALE CLIENTS: Are you undergoing any hormone replacement therapy treatments?*
No
Yes
N/A

If yes, please specify:
MALE CLIENTS: Do you experience irritation from shaving?*
No
Yes
N/A

If yes, please specify:
MALE CLIENTS: Do you experience ingrown hairs as a result of hair removal?*
No
Yes
N/A
May I call you at the provided phone number to confirm future appointments?*
No
Yes
May I contact you via mail/email about future promotions and news?*
No
Yes

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that its 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. 

Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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