Client Consultation
Date: ______________________________
Name: __________________________________________________________
Date of Birth:__________________
Address: _________________________________________________________
Phone: __________________________________ Cell Phone: ______________
E-mail address: ____________________________
Employer: ________________________________
Referred by:________________________________________________________
What would you like to achieve from your treatment today? ________________
Have you ever had a facial treatment before? No Yes, when? ______________
Have you ever received- Laser, IPL, or Radio Frequency treatments? _No _ Yes
when?_________________
Have you experienced Botox, Dermal Fillers or other cosmetic injections? No Yes
specify: ____________________________________________________________
Have you ever had chemical peels, laser or micro-dermabrasion In the last month?
Do you use Retin-A, Renova, Adapalene, Hydroxyl Acid? No Yes
describe: ____________________________________________________________
Have you used any of these products in the last month? No Yes
Which of the following best describes your skin type? (Please circle one type number)
I Creamy complexion Always burns easily, never tans
II Light Complexion Always burns, tans slightly
III Light/Matte Complexion Burns moderately, tans gradually
IV Matte Complexion Seldom burns, always tans well
V Brown Complexion Rarely burns, deep tan
VI Black Complexion Never burns, deeply pigmented
____________________________________________________________________________________
Client Consultation—Continued
Do you have any special skin problems or concerns pertaining to your face or body? Yes No
specify:
8) Have you used an acne medication? No Yes, when?
___________ Which drug? ____________________
10) Have you recently used any self-tanning lotions, creams or treatments? No Yes
11) Have you used any of the following hair removal methods in the past six weeks? No Yes
circle all that apply.
Shaving Waxing Electrolysis Plucking Tweezing Stringing Depilatories
12) What areas of concern do you have regarding your:
Skin: (Please check any that apply and explain)
Breakouts/acne
Blackheads/whiteheads
Excessive oil/shine
Rosacea
Broken capillaries
Redness/ruddiness
Sun spot/liver spot/brown spot
Uneven skin tone
Sun damage
Wrinkles/fine lines
Dull/dry skin
Flaky
13) Please list current medications/conditions.____________________________________
14) What SPF do you use on your face? ____________ How often/when? _____________
Clairisonic Ultrasound brush? __No__Yes
Galvanic spa or Microcurrent?___No__Yes
Cleanser __________________________________
Toner _____________________________________
Day Moisturizer ____________________________
Eye Products _______________________________
Night Moisturizer/Cream _____________________
SPF/Sunscreen______________________________
Other _____________________________________
Makeup Products ___________________________
___________________________________________
13) Have you ever had an allergic reaction to any of the following? (Please check any that apply and explain)
Cosmetics
Fragrance
Sunscreens
Iodine
Pollen
AHAs
Latex
If yes, please explain: ____________________________________________
Have you had any recent tanning bed or sun exposure? No Yes
specify: _________________________________________________________
Female Clients Only:
Are you taking oral contraceptives? No Yes
specify: ___________________________________________________________
_______________________
Any recent changes to or from your contraceptive treatment ? No Yes
If so, what and when: _______________________________________________
Are you pregnant or trying to become pregnant? No Yes
Are you lactating? No Yes
___________________________________________________________________
Are you undergoing any hormone replacement therapy? No Yes
specify: ____________________________________________________________
Male Clients Only:
What is your current shaving system? Wet shave or Electric ?
Do you experience irritation from shaving? No Yes Ingrown hairs? No Yes
___________________________________________________________________
Future Appointments/Contact:
Do you prefer I call you at your home, work or cell phone number to confirm future appointments, or email?
Please list__________
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 Quality Aesthetics & Laser from liability
and assume full responsibility thereof.
Consent to treat with Laser ___Q-Switch 532-KTP___ Q-Switch 1064___Erbium Yag___
Client Signature: __________________________________________________________ Date: