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Contact Details

Please fill out this form on your first appointment.

Your answers will better help us to meet your needs and ensure that you have a happy and satisfying experience.

Full Name *

Street Address

City

State/Province

ZIP / Postal Code

Email Address *

Date of Birth *

Phone *

Emergency Contact Phone

Have you ever had a facial treatment before?YesNo

If yes, when was that?

What would you like to achieve from your treatment today?

Do you have any special skin problems or concerns pertaining to your face or body?YesNo

If yes, please specify

Have you experienced Botox, Restylane or Collagen injections?YesNo

If yes, please specify

Do you ever experience these conditions on your skin?FlakinessTightnessObvious dryness

What SPF do you use on your face?

How often/when?

YOUR HEALTH

This information is to ensure we carry out the appropriate treatments for you, taking into consideration any medical conditions which might have treatment contraindications.
* Female clients only

Any other medical conditions?

Are you taking any medications?

Do you suffer from any allergies?

Do you smoke?YesNo

Are you healing impaired?YesNo

Do you follow a restricted diet?YesNo

Within the last nine months, have you undergone any surgery?YesNo

Within the last year, have you been under a dermatologist or other physician’s care?YesNo

How would you describe your stress levels from 1- 10 (1=Iow, 10=high):

How frequently do you exercise:Everyday3 times weekOnce a weekIrregularly

Describe your own:

How much plain water do you consume daily?1-23-56-10Over 10

MALE CLIENTS ONLY

What is your current shaving system?ElectricWet Shave

Do you experience irritation from shaving?YesNo

Do you experience ingrown hairs?YesNo

Any other information?

Have you recently received any of the following treatment?

If yes please specify the date you received your last treatment

Microdermabrasion

Chemical Peel

Lash Tint

Brow Tint

Micro Needling

Facial Waxing

Laser resurfacing

CONSENT

I confirm that the information given above is correct, and that to my knowledge, I have not withheld any information that may be deemed relevant to the treatment I am receiving. I acknowledge that there are potential risks and complications to receiving any procedure, and I take responsibility for any side effects should they occur. I consent to the facial & skin treatment with the understanding that it is an elective procedure, no medical claims are expressed.

I certify that I have read and fully understand the above paragraphs, that I have had sufficient opportunity for discussion and to ask questions, and that I hereby consent to the procedure described above.

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Contact Details