Client Information & Consultation
Please fill out this form as best you can so we can provide you with the most relevant service.
First and Last Name
Phone Number
Your skin Goals and Concerns
Skin Type
Normal/combo
oily
dry
mild acne
moderate acne
mature & aging
none of the above
What makeup products are you currently using?
Does your job and lifestyle require you to work/play outdoors?
Do you wax your facial skin on a regular basis?
Are you using any Topical prescribed by a doctor?
Have you ever had facials, chemical peels, microdermabrasion or any resurfacing treatments? If yes when? If yes , was it within the last month?
Are you using Retin-A? If yes, when?
Are you using Benzoyl Peroxide? Do you have any allergies or sensitivities ?
Have you ever experienced a reaction to any of the following ?
cosmetics
medicine
iodine (shellfish)
latex
pollen
food/fruit
animals
fragrance
alpha hydroxy acids
sunscreens
none of above
Do you have any of the following health issues?
Cancer
Circulatory issues?
Arthritis
Hormonal imbalance?
Diabeties?
Lactating ?
Cold Sores ?
Chemotherapy?
High Blood pressure?
Hysterectomy?
Thyroid?
Pregnant?
Planning to be pregnant?
Recent surgeries?
Eczema?
none of above
Do you take any medications?
Accutane
Antibiotics
Birth control
none of the above
Date
Your Signature
Clear
Additional Photos
Face Photos (Front, & both sides of the face)
Skincare Therapist Notes
Does Ski Esthetics have permission to take videos/photos during the time of your appointment to advertise business?
Yes
No
I have read and completed this questionnaire truthfully. I understand that withholding information or providing misinformation may result in contraindications and or/ irritation to the skin from treatments received.
Email
What skincare products are you currently using.
Send
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