EmailMeForm
SKIN CARE CONSULTATION FORM
Please fill this form out prior to your appointment.
Name
*
First
Last
Email
*
Contact Number
*
Date of your appointment
MM
/
DD
/
YYYY
Have you ever had a facial?
*
Yes
No
How often?
Medical Data
Do you have any current medical conditions?
Yes
No
If yes, please list
Are you taking any medication?
Yes
No
If yes, please list
Topical medications?
Yes
No
If yes, please list
Do you have any allergies?
Yes
No
If yes, please list
Describe your current skin care routine. Please list brand.
Cleanser
Scrub
Toner
Moisturizer
Sun Block
Other
Have you had any cosmetic surgery?
Yes
No
Please note: 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. (please initial below that you have read this statement)
*
