Consultation FormPlease fill in your consultation form prior to your appointment. Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone Number * How did you hear about me? Occupation * Does your job require that you work outdoors? * Yes No Have you every had a facial service or wax before? * Yes No If so, please describe: * Which of the following best describes your skin type? (Please check one) Type I Fair skin tones—Always burns, never tans Type II Light skin tones—Burns easily, tans slightly Type III Fair to olive skin tones—Burns moderately, tans moderately Type IV Light brown skin tones—Burns slightly, tans easily Type V Dark brown skin tones—Rarely burns, tans easily Type VI Dark brown to black skin tones—Never burns, tans easily Do you have any special skin problems or concerns pertaining to your face or body? * Yes No If yes, please specify: Do you use Accutane, Retin-A, Renova, Adapalene Hydroxyl Acid or any other Retinol/vitamin A derivative products? * Yes No If yes, please specify when last used: Have you used acne medication? * Yes No If yes, please specify which medication and when it was last used: Have you experienced Botox, Restylane, or collagen injections? * Yes No If yes, please specify: What skin care products are you currently using? (List brands if known) * Have you used any hair removal methods in the past six weeks? * Yes No Check all that apply Shaving Waxing Electrolysis Tweezing Threading Depilatories Other What areas of concern do you have regarding your: Skin * Breakouts/Acne Uneven skin tone Blackheads/whiteheads Sun Damage Excessive oil/shine Wrinkles/fine lines Rosacea Dull/dry skin Broken capillaries Flaky skin Redness/ruddiness Dehydrated Sun/liver/brown spots Other What areas of concern do you have regarding your: Eyes * Dehydrated Wrinkles Puffiness Dark Circles Other What areas of concern do you have regarding your: Lips * Dehydrated Cracked/chapped lips Other Have you ever had an allergic reaction to any of the following (Check all that apply) * Cosmetics AHAs Medication Fragrance Food Shellfish Animals Latex Sunscreens Drugs Iodine Pollen Other None If yes, please specify: Do you use SPF on your face? * Yes No If yes, please specify how often/when: Have you had any recent tanning bed or sun exposure that changed the color of your skin? * Yes No If yes, please specify: Have you recently used any self-tanning lotions, creams or treatments? * Yes No If yes, please specify: How many glasses of water do you drink per day? (Please check one) * < 1 glass 1-3 glasses 4-7 glasses 8+ glasses How many caffeinated beverages (coffee, tea, soda, etc.) do you consume per day? (Please check one) * None 1-2 drinks 3-5 drinks 6+ drinks How many alcoholic beverages do you consume per week? (Please check one) * I don't drink 1-3 drinks 4-7 drinks 8+ drinks How many hours of sleep do you get per night? (Please check one) * < 3 hours 3-5 hours 6-8 hours 8-10 hours 10+ hours Which foods do you consume on a regular basis? * Fruits Vegetables Dairy/Eggs Cheese Poultry Fish Grains/Bread Processed Sugar Processed Meats What does your daily commute look like? * Car Bike Public Transport Walk I don't commute How often do you travel on a plane? * Never 1- 2 times per year 1-2 times per quarter Every month Every week How many hours do you spend in front of a screen or digital device? * < 3 hours 4-6 hours 7-9 hours 10-12 hours 12+ hours Do you exercise on a regular basis? * Yes No Do you smoke cigarettes, vape, or consume other tobacco products? * Yes No What are your stress levels on a scale from 1 to 5 (1 = low stress, 5 = high stress) * 1 2 3 4 5 Are you taking oral contraceptives? * Oral contraceptives can cause photosensitivity Yes No Not applicable Are you pregnant or trying to become pregnant? * Yes No Not applicable Are you experiencing any menopausal symptoms? * Yes No Not applicable If yes, please specify: Are you undergoing any hormone replacement therapy treatments? * Yes No If yes, please specify: Do you experience irritation from shaving? * Yes No If yes, please specify: Do you experience ingrown hairs as a result of hair removal? * Yes No If yes, please specify: May I contact you at the provided phone number to confirm future appointments? * Yes No May I contact you via mail/email about future promotions and news? * Yes No Thank you!