EmailMeForm
Original Flair Online Skincare Consultation Form
Please complete this form before your appointment. By completing this client profile, you will be helping us to correctly evaluate your skin care needs. All information will be kept in strict confidence.
Name
First
Last
Email
Best Contact Phone#
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Cell Phone Numbers:
(Include cell carrier only if you entered cell # above as best contact phone number and would like to receive appointment confirmations and reminders by text message.)
Cell Carrier
How did you hear about us?
Groupon
Google
Valpak
Local Newspaper
Other
If referred by a friend please list name first and last
When was your last facial?
What skin improvements would like to see?
List any known allergies to foods, flowers or products
What skincare products do you currently use?
Choose which best describes your skin
Dry
Oily
Combination
Sensitive
Acne
If you suffer with acne, choose how would you characterize the severity:
Please select
Mild (red bumps and pustules that come and go)
Moderate (red bumps and pustules that come and go)
Severe (persistent nodules and cysts that are resistant to treatment)
Are you currently taking Accutane?
Please select
Yes
No
Have you been diagnosed with either of the following
Rosacea
Psoriasis
Do you have any of the following skin conditions
fine lines around eyes and mouth
saggy facial skin
enlarged pores
blotchy or uneven pigment
List any medical conditions example high blood pressure or diabetes
List all medications you take regularly including hormones, vitamins, etc.
Have you ever undergone treatment from a dermatologist? If so, for what condition?
Have you ever undergone plastic surgery? If so, when and where on your body?
Have you ever had chemical peels, laser, microdermabrasion or any resurfacing treatments?
Do you use any specialty products (eye creams, scrubs, masks, etc.)? If so, which ones?
Have you ever had body or facial waxing? If so, what areas?
Female Clients Only
Are you taking oral contraceptives?
Are you pregnant and seeing changes in your skin?
If pregnant, what changes are you seeing?
Male Clients
What is your current shaving system? Electric or Wet Shave
Do you experience irritation from shaving?
Do you experience ingrown hairs?
Please list any additional information or concerns you may have about your skin or questions you may have regarding skincare services.
Today's Date
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If you already scheduled your appointment enter the date here
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What time is your appointment
