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Client Consultation Form-Skin

Client Consultation Form-Skin


First Participant's Name
First Name*
Middle Name
Last Name*
Phone*
Select Gender
First Participant's Date of Birth*
Date of Birth
First Participant's Client Consultation-Skin
Your skincare goals: *
During your facial, do you prefer: *
Quiet/relaxing
Chatting
Either is fine
How would you describe your skin? *
Normal
Dry
Combination
Sensitive
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
What are your top concerns? *
Acne/Breakouts
Blackheads/Congestion
Texture
Redness/Sensitivity
Fine Lines/Wrinkles
Hyperpigmentation/Dark Spots
Dehydration
Dullness
None
Others:
Do you currently have any active skin conditions? *
Eczema
Psoriasis
Rosacea
Dermatitis
None
Others skin conditions:
Are you experiencing any of the following? *
Sunburn
Open wounds
Recent extractions/dermatology treatments
None
Are you taking any medications?*
No
Yes
If yes - List:
Are you using any of the following products? *
Retinol/Retnoid
AHA/BHA acids (glycolic, salicylic, lactic)
Benzoyl Peroxide
Vitamin C
Prescription creams
None
Recent treatments: *
Botox/Fillers
Chemical Peel
Laser
Microneedling
None
If check off please provide date
Are you pregnant or breastfeeding?*
No
Yes
What skin care products are you currently using? (List brands if known)
Do you have any allergies?*
No
Yes
If yes-List allergies:
Sensitivities: *
Fragrance
Essential Oils
Latex
SPF
Other:
Please list any other sensitivities:
What does your current routine look like?
How often do you exfoliate? *
Daily
A few times a week
Weely
Rarely/Never
Do you get professional facials? *
First time
Occasionally
Regularly
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
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*
Select Gender
Participant's Date of Birth*
Date of Birth
Second Participant's Client Consultation-Skin
Your skincare goals: *
During your facial, do you prefer: *
Quiet/relaxing
Chatting
Either is fine
How would you describe your skin? *
Normal
Dry
Combination
Sensitive
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
What are your top concerns? *
Acne/Breakouts
Blackheads/Congestion
Texture
Redness/Sensitivity
Fine Lines/Wrinkles
Hyperpigmentation/Dark Spots
Dehydration
Dullness
None
Others:
Do you currently have any active skin conditions? *
Eczema
Psoriasis
Rosacea
Dermatitis
None
Others skin conditions:
Are you experiencing any of the following? *
Sunburn
Open wounds
Recent extractions/dermatology treatments
None
Are you taking any medications?*
No
Yes
If yes - List:
Are you using any of the following products? *
Retinol/Retnoid
AHA/BHA acids (glycolic, salicylic, lactic)
Benzoyl Peroxide
Vitamin C
Prescription creams
None
Recent treatments: *
Botox/Fillers
Chemical Peel
Laser
Microneedling
None
If check off please provide date
Are you pregnant or breastfeeding?*
No
Yes
What skin care products are you currently using? (List brands if known)
Do you have any allergies?*
No
Yes
If yes-List allergies:
Sensitivities: *
Fragrance
Essential Oils
Latex
SPF
Other:
Please list any other sensitivities:
What does your current routine look like?
How often do you exfoliate? *
Daily
A few times a week
Weely
Rarely/Never
Do you get professional facials? *
First time
Occasionally
Regularly
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
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*
Select Gender
Participant's Date of Birth*
Date of Birth
Third Participant's Client Consultation-Skin
Your skincare goals: *
During your facial, do you prefer: *
Quiet/relaxing
Chatting
Either is fine
How would you describe your skin? *
Normal
Dry
Combination
Sensitive
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
What are your top concerns? *
Acne/Breakouts
Blackheads/Congestion
Texture
Redness/Sensitivity
Fine Lines/Wrinkles
Hyperpigmentation/Dark Spots
Dehydration
Dullness
None
Others:
Do you currently have any active skin conditions? *
Eczema
Psoriasis
Rosacea
Dermatitis
None
Others skin conditions:
Are you experiencing any of the following? *
Sunburn
Open wounds
Recent extractions/dermatology treatments
None
Are you taking any medications?*
No
Yes
If yes - List:
Are you using any of the following products? *
Retinol/Retnoid
AHA/BHA acids (glycolic, salicylic, lactic)
Benzoyl Peroxide
Vitamin C
Prescription creams
None
Recent treatments: *
Botox/Fillers
Chemical Peel
Laser
Microneedling
None
If check off please provide date
Are you pregnant or breastfeeding?*
No
Yes
What skin care products are you currently using? (List brands if known)
Do you have any allergies?*
No
Yes
If yes-List allergies:
Sensitivities: *
Fragrance
Essential Oils
Latex
SPF
Other:
Please list any other sensitivities:
What does your current routine look like?
How often do you exfoliate? *
Daily
A few times a week
Weely
Rarely/Never
Do you get professional facials? *
First time
Occasionally
Regularly
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
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*
Select Gender
Participant's Date of Birth*
Date of Birth
Fourth Participant's Client Consultation-Skin
Your skincare goals: *
During your facial, do you prefer: *
Quiet/relaxing
Chatting
Either is fine
How would you describe your skin? *
Normal
Dry
Combination
Sensitive
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
What are your top concerns? *
Acne/Breakouts
Blackheads/Congestion
Texture
Redness/Sensitivity
Fine Lines/Wrinkles
Hyperpigmentation/Dark Spots
Dehydration
Dullness
None
Others:
Do you currently have any active skin conditions? *
Eczema
Psoriasis
Rosacea
Dermatitis
None
Others skin conditions:
Are you experiencing any of the following? *
Sunburn
Open wounds
Recent extractions/dermatology treatments
None
Are you taking any medications?*
No
Yes
If yes - List:
Are you using any of the following products? *
Retinol/Retnoid
AHA/BHA acids (glycolic, salicylic, lactic)
Benzoyl Peroxide
Vitamin C
Prescription creams
None
Recent treatments: *
Botox/Fillers
Chemical Peel
Laser
Microneedling
None
If check off please provide date
Are you pregnant or breastfeeding?*
No
Yes
What skin care products are you currently using? (List brands if known)
Do you have any allergies?*
No
Yes
If yes-List allergies:
Sensitivities: *
Fragrance
Essential Oils
Latex
SPF
Other:
Please list any other sensitivities:
What does your current routine look like?
How often do you exfoliate? *
Daily
A few times a week
Weely
Rarely/Never
Do you get professional facials? *
First time
Occasionally
Regularly
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
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*
Select Gender
Participant's Date of Birth*
Date of Birth
Fifth Participant's Client Consultation-Skin
Your skincare goals: *
During your facial, do you prefer: *
Quiet/relaxing
Chatting
Either is fine
How would you describe your skin? *
Normal
Dry
Combination
Sensitive
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
What are your top concerns? *
Acne/Breakouts
Blackheads/Congestion
Texture
Redness/Sensitivity
Fine Lines/Wrinkles
Hyperpigmentation/Dark Spots
Dehydration
Dullness
None
Others:
Do you currently have any active skin conditions? *
Eczema
Psoriasis
Rosacea
Dermatitis
None
Others skin conditions:
Are you experiencing any of the following? *
Sunburn
Open wounds
Recent extractions/dermatology treatments
None
Are you taking any medications?*
No
Yes
If yes - List:
Are you using any of the following products? *
Retinol/Retnoid
AHA/BHA acids (glycolic, salicylic, lactic)
Benzoyl Peroxide
Vitamin C
Prescription creams
None
Recent treatments: *
Botox/Fillers
Chemical Peel
Laser
Microneedling
None
If check off please provide date
Are you pregnant or breastfeeding?*
No
Yes
What skin care products are you currently using? (List brands if known)
Do you have any allergies?*
No
Yes
If yes-List allergies:
Sensitivities: *
Fragrance
Essential Oils
Latex
SPF
Other:
Please list any other sensitivities:
What does your current routine look like?
How often do you exfoliate? *
Daily
A few times a week
Weely
Rarely/Never
Do you get professional facials? *
First time
Occasionally
Regularly
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
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*
Select Gender
Participant's Date of Birth*
Date of Birth
Sixth Participant's Client Consultation-Skin
Your skincare goals: *
During your facial, do you prefer: *
Quiet/relaxing
Chatting
Either is fine
How would you describe your skin? *
Normal
Dry
Combination
Sensitive
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
What are your top concerns? *
Acne/Breakouts
Blackheads/Congestion
Texture
Redness/Sensitivity
Fine Lines/Wrinkles
Hyperpigmentation/Dark Spots
Dehydration
Dullness
None
Others:
Do you currently have any active skin conditions? *
Eczema
Psoriasis
Rosacea
Dermatitis
None
Others skin conditions:
Are you experiencing any of the following? *
Sunburn
Open wounds
Recent extractions/dermatology treatments
None
Are you taking any medications?*
No
Yes
If yes - List:
Are you using any of the following products? *
Retinol/Retnoid
AHA/BHA acids (glycolic, salicylic, lactic)
Benzoyl Peroxide
Vitamin C
Prescription creams
None
Recent treatments: *
Botox/Fillers
Chemical Peel
Laser
Microneedling
None
If check off please provide date
Are you pregnant or breastfeeding?*
No
Yes
What skin care products are you currently using? (List brands if known)
Do you have any allergies?*
No
Yes
If yes-List allergies:
Sensitivities: *
Fragrance
Essential Oils
Latex
SPF
Other:
Please list any other sensitivities:
What does your current routine look like?
How often do you exfoliate? *
Daily
A few times a week
Weely
Rarely/Never
Do you get professional facials? *
First time
Occasionally
Regularly
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
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*
Select Gender
Participant's Date of Birth*
Date of Birth
Seventh Participant's Client Consultation-Skin
Your skincare goals: *
During your facial, do you prefer: *
Quiet/relaxing
Chatting
Either is fine
How would you describe your skin? *
Normal
Dry
Combination
Sensitive
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
What are your top concerns? *
Acne/Breakouts
Blackheads/Congestion
Texture
Redness/Sensitivity
Fine Lines/Wrinkles
Hyperpigmentation/Dark Spots
Dehydration
Dullness
None
Others:
Do you currently have any active skin conditions? *
Eczema
Psoriasis
Rosacea
Dermatitis
None
Others skin conditions:
Are you experiencing any of the following? *
Sunburn
Open wounds
Recent extractions/dermatology treatments
None
Are you taking any medications?*
No
Yes
If yes - List:
Are you using any of the following products? *
Retinol/Retnoid
AHA/BHA acids (glycolic, salicylic, lactic)
Benzoyl Peroxide
Vitamin C
Prescription creams
None
Recent treatments: *
Botox/Fillers
Chemical Peel
Laser
Microneedling
None
If check off please provide date
Are you pregnant or breastfeeding?*
No
Yes
What skin care products are you currently using? (List brands if known)
Do you have any allergies?*
No
Yes
If yes-List allergies:
Sensitivities: *
Fragrance
Essential Oils
Latex
SPF
Other:
Please list any other sensitivities:
What does your current routine look like?
How often do you exfoliate? *
Daily
A few times a week
Weely
Rarely/Never
Do you get professional facials? *
First time
Occasionally
Regularly
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
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*
Select Gender
Participant's Date of Birth*
Date of Birth
Eighth Participant's Client Consultation-Skin
Your skincare goals: *
During your facial, do you prefer: *
Quiet/relaxing
Chatting
Either is fine
How would you describe your skin? *
Normal
Dry
Combination
Sensitive
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
What are your top concerns? *
Acne/Breakouts
Blackheads/Congestion
Texture
Redness/Sensitivity
Fine Lines/Wrinkles
Hyperpigmentation/Dark Spots
Dehydration
Dullness
None
Others:
Do you currently have any active skin conditions? *
Eczema
Psoriasis
Rosacea
Dermatitis
None
Others skin conditions:
Are you experiencing any of the following? *
Sunburn
Open wounds
Recent extractions/dermatology treatments
None
Are you taking any medications?*
No
Yes
If yes - List:
Are you using any of the following products? *
Retinol/Retnoid
AHA/BHA acids (glycolic, salicylic, lactic)
Benzoyl Peroxide
Vitamin C
Prescription creams
None
Recent treatments: *
Botox/Fillers
Chemical Peel
Laser
Microneedling
None
If check off please provide date
Are you pregnant or breastfeeding?*
No
Yes
What skin care products are you currently using? (List brands if known)
Do you have any allergies?*
No
Yes
If yes-List allergies:
Sensitivities: *
Fragrance
Essential Oils
Latex
SPF
Other:
Please list any other sensitivities:
What does your current routine look like?
How often do you exfoliate? *
Daily
A few times a week
Weely
Rarely/Never
Do you get professional facials? *
First time
Occasionally
Regularly
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
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*
Select Gender
Participant's Date of Birth*
Date of Birth
Ninth Participant's Client Consultation-Skin
Your skincare goals: *
During your facial, do you prefer: *
Quiet/relaxing
Chatting
Either is fine
How would you describe your skin? *
Normal
Dry
Combination
Sensitive
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
What are your top concerns? *
Acne/Breakouts
Blackheads/Congestion
Texture
Redness/Sensitivity
Fine Lines/Wrinkles
Hyperpigmentation/Dark Spots
Dehydration
Dullness
None
Others:
Do you currently have any active skin conditions? *
Eczema
Psoriasis
Rosacea
Dermatitis
None
Others skin conditions:
Are you experiencing any of the following? *
Sunburn
Open wounds
Recent extractions/dermatology treatments
None
Are you taking any medications?*
No
Yes
If yes - List:
Are you using any of the following products? *
Retinol/Retnoid
AHA/BHA acids (glycolic, salicylic, lactic)
Benzoyl Peroxide
Vitamin C
Prescription creams
None
Recent treatments: *
Botox/Fillers
Chemical Peel
Laser
Microneedling
None
If check off please provide date
Are you pregnant or breastfeeding?*
No
Yes
What skin care products are you currently using? (List brands if known)
Do you have any allergies?*
No
Yes
If yes-List allergies:
Sensitivities: *
Fragrance
Essential Oils
Latex
SPF
Other:
Please list any other sensitivities:
What does your current routine look like?
How often do you exfoliate? *
Daily
A few times a week
Weely
Rarely/Never
Do you get professional facials? *
First time
Occasionally
Regularly
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
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*
Select Gender
Participant's Date of Birth*
Date of Birth
Tenth Participant's Client Consultation-Skin
Your skincare goals: *
During your facial, do you prefer: *
Quiet/relaxing
Chatting
Either is fine
How would you describe your skin? *
Normal
Dry
Combination
Sensitive
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
What are your top concerns? *
Acne/Breakouts
Blackheads/Congestion
Texture
Redness/Sensitivity
Fine Lines/Wrinkles
Hyperpigmentation/Dark Spots
Dehydration
Dullness
None
Others:
Do you currently have any active skin conditions? *
Eczema
Psoriasis
Rosacea
Dermatitis
None
Others skin conditions:
Are you experiencing any of the following? *
Sunburn
Open wounds
Recent extractions/dermatology treatments
None
Are you taking any medications?*
No
Yes
If yes - List:
Are you using any of the following products? *
Retinol/Retnoid
AHA/BHA acids (glycolic, salicylic, lactic)
Benzoyl Peroxide
Vitamin C
Prescription creams
None
Recent treatments: *
Botox/Fillers
Chemical Peel
Laser
Microneedling
None
If check off please provide date
Are you pregnant or breastfeeding?*
No
Yes
What skin care products are you currently using? (List brands if known)
Do you have any allergies?*
No
Yes
If yes-List allergies:
Sensitivities: *
Fragrance
Essential Oils
Latex
SPF
Other:
Please list any other sensitivities:
What does your current routine look like?
How often do you exfoliate? *
Daily
A few times a week
Weely
Rarely/Never
Do you get professional facials? *
First time
Occasionally
Regularly
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
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*
Select Gender
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Client Consultation-Skin
Your skincare goals: *
During your facial, do you prefer: *
Quiet/relaxing
Chatting
Either is fine
How would you describe your skin? *
Normal
Dry
Combination
Sensitive
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
What are your top concerns? *
Acne/Breakouts
Blackheads/Congestion
Texture
Redness/Sensitivity
Fine Lines/Wrinkles
Hyperpigmentation/Dark Spots
Dehydration
Dullness
None
Others:
Do you currently have any active skin conditions? *
Eczema
Psoriasis
Rosacea
Dermatitis
None
Others skin conditions:
Are you experiencing any of the following? *
Sunburn
Open wounds
Recent extractions/dermatology treatments
None
Are you taking any medications?*
No
Yes
If yes - List:
Are you using any of the following products? *
Retinol/Retnoid
AHA/BHA acids (glycolic, salicylic, lactic)
Benzoyl Peroxide
Vitamin C
Prescription creams
None
Recent treatments: *
Botox/Fillers
Chemical Peel
Laser
Microneedling
None
If check off please provide date
Are you pregnant or breastfeeding?*
No
Yes
What skin care products are you currently using? (List brands if known)
Do you have any allergies?*
No
Yes
If yes-List allergies:
Sensitivities: *
Fragrance
Essential Oils
Latex
SPF
Other:
Please list any other sensitivities:
What does your current routine look like?
How often do you exfoliate? *
Daily
A few times a week
Weely
Rarely/Never
Do you get professional facials? *
First time
Occasionally
Regularly
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
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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