Client Consultation Form Name * First Name Last Name Email * Phone * (###) ### #### What service are you getting today? * Facial Waxing Lashes/Brows What is your goal with this treatment? * Have you had this treatment before? * Yes No Do you have any specific skin concerns? * Have you had a chemical peel, microdermabrasion, or laser treatments in the past month? * Yes No Do you use Accutane, Tretinoin, Retin-A, or Retinol/Vitamin A products? * Yes No Have you received Botox, filler, or other injections within the past 2 weeks? * Yes No What skincare products are you currently using? Cleanser Exfoliant Toner Masks Serum Moisturizer SPF Eye Cream Which of the following apply to your skin concerns? Acne/Breakouts Sun Damage Rosacea Flaky Skin Uneven Skin Tone Skin Texture Excess Oil Dryness/Dullness Redness/Irritation Blackheads/Whiteheads Fine Lines/Wrinkles Please list any allergies. * Do you use tanning beds? * Yes No Are you pregnant or trying to get pregnant? * Yes No I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it 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. * Thank you!
