Skin Care Consultation Form
Please fill out this form prior to your appointment.
Name
Email
Contact Number
Date of Your Appointment
Have you ever had a facial?
Yes
No
How often?
Which of the following statements apply?
I have a medical condition.
I am taking medication or topical medication.
I have allergies.
I have had cosmetic surgery.
If any statements were checked above, please list or provide more details.
Describe your current skin care routine. Please list the brand. (Cleanser, Scrub, Toner, Moisturizer, Sun Block, Other)
Acknowledge the following:
A facial may cause the skin to purge resulting in a break out. This is normal and does not mean you are having a reaction to the products. If you experience any itching, burning, or rash following your facial treatment please notify the professional immediately so he or she can assist you in finding a better product for your skin. (please initial below that you have read this statement)
I will notify the professional of any changes to my skin care routine or medications prior to any future treatments.
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