Facial Consultation Form - Sundays Day Spa And Salon
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2FACIAL CONSULTATION FORM
Today’s Date: ______________
Name ____________________________________________________________ Birthday ________________________
Address __________________________________________________________________________________________
City ____________________________________________ State __________________ Zip code ___________________
Home Phone # __________________________ Work Phone # ___________________ Other _____________________
Occupation ________________________________________________________________________________________
Marital Status _________ Male _______ Female ______ Emergency Contact _____________________ # ___________
MEDICAL HISTORY
Check Box Where Applicable/Fill In With Details:
( ) Accutane
( ) Acne
( ) Allergies : ______________________________________________
( ) Arthritis
( ) Depression
( ) Diabetic
( ) Epilepsy
( ) Eczema
( ) Heart Condition
( ) Fever Blisters
( ) Hepatitis
( ) Blood Pressure: () high () low
( ) HIV
( ) Insomnia
( ) Hyper/Hypo Pigmentation
( ) Lupus
( ) Pregnant
( ) Hyper/Hypo Thyroid
( ) Plastic Surgery
( ) Retin-A
( ) Medications: ______________________________________________
( ) Psoriasis
( ) Seborrhea
( ) Skin Cancer
( ) Vitamins
( ) Underweight
( ) Surgeries: ________________________________________________
( ) Rashes
( ) Overweight
( ) Shingles
( ) Warts
( ) Other: ______________________________________________________________________
PERSONAL SKIN CARE HISTORY
Please Check Current Products you use:
( ) Eye Make-Up Remover
( ) Cleansing Cream
( ) Facial Soap
( ) Skin Toner/ Astringent
( ) Day Cream
( ) Night Cream
( ) Eye Cream
( ) Neck Cream
( ) Mask
( ) Facial Scrub
( ) Exfoliants
( ) Body Soap
( ) Body Lotion/Cream
( ) Body Scrub
( ) Hand Cream
PERSONAL EVALUATION QUESTIONNAIRE
Please Reply In Detail To the Following Questions:
1.
How did you hear about us?
____________________________________________________________________________
2.
What is your major reason for being here today?
____________________________________________________________________________
____________________________________________________________________________
(Continued)
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Parent category: Business