Client Consultation Form printable pdf download

Client Consultation

Date: ______________________________

Name: __________________________________________________________ Date of Birth: __________________

Address: ________________________________________________________________________________________

Home Phone: __________________________________Business Phone: __________________________________

Cell Phone:______________________________________E-mail address: __________________________________

Single: H No H Yes

Married: H No H Yes If yes, anniversary date: ___________________

Employer: ________________________________________Occupation: __________________________________

H No H Yes

Does your job require that you work outdoors?

Referred by:______________________________________________________________________________________

What would you like to achieve from your treatment today? ____________________________________________

Your Skin Care

H No H Yes, when? _________________

1) Have you ever had a facial treatment before?

H No H Yes, when? _________________

2) Have you ever had a body spa treatment before?

H No H Yes

Massage:

H No H Yes

Salt glow:

H No H Yes

Seaweed wrap:

H No H Yes

Moor mud:

H No H Yes

Body scrub:

Other: ___________________________________________________

3) Which of the following best describes your skin type? (Please circle one type number)

Creamy complexion

Always burns easily, never tans

Light Complexion

Always burns, tans slightly

III

Light/Matte Complexion

Burns moderately, tans gradually

Matte Complexion

Seldom burns, always tans well

Brown Complexion

Rarely burns, deep tan

Black Complexion

Never burns, deeply pigmented

4) Do you have any special skin problems or concerns pertaining to your face or body? H Yes H No

specify: ____________________________________________________________________________________

5) Have you ever had chemical peels, laser or microdermabrasion? H No H Yes In the last month? H No H Yes

6) Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products? H No H Yes

describe: __________________________________________________________________________________

7) Have you used any of these products in the last 3 months? H No H Yes

Client Consultation Form

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