Client Consultation Form

**Please complete and submit this form at least 2 days prior to your treatment.**

"*" indicates required fields

Name*

First Last

Phone*

Email*

Date of Birth

Occupation

Today my skin feels: **

Dry

Dehydrated

Sensitive/Irritated

Oily/Congested

Normal

Combo/Oily

Combo/Dry

Itchy/Flaky

My skin could use improvement in: **

Other (if checked above)

Please list the products you use for daily skin care below, and whether you use them in the AM, PM, or BOTH.*

Cleanser, Toner, Moisturizer, Exfoliation, Mask, Etc

Do you have a skincare ritual that changes with the seasons? If so, please describe below.

Are you interested in changing/purchasing new skin care products?*

Yes

Maybe/Unsure

What brand of sunscreen do you use?*

Are there any health/medical concerns or allergies I need to be aware of today? Please elaborate if yes.*

Are you currently taking any vitamins, supplements, herbs, prescription, nonprescription medications or remedies? Please list if yes.*

Are you currently undergoing cancer treatment? If yes, please bring a note from your medical provider to your session.*

Yes

Thyroid Health*

Normal

Abnormal

Are you pregnant?*

Yes

Maybe

Current Life Stage*

Menstruating

Menopausal

Post-Menopausal

Post-Hysterectomy

Essential oil/fragrance preferences?*

Have you ever had a facial of any kind previously?*

Do you follow a vegan diet?*

Yes

Are you allergic to any of the following?*

Wheat

Nuts

Gluten

Please elaborate on allergies if needed.

My Energy Level is:*

High

Moderate (balanced)

Low

Areas of tension in my body:*

Neck/Shoulders

Torso/midback

Lower back/hips

Arms/hands

Legs/feet

None

My overall body temperature feels:

Cool

Warm to hot

Cold with poor circulation

Things to remember:

Payment: Cash or check accepted at the time of your appointment.

Please refrain from wearing perfume and make-up to appointments.

If wearing contacts, please remove them before facial treatment.

Please be on time. I cannot guarantee full treatment time if you arrive late.

Cancellation Policy: If you need to cancel or reschedule your appointment, please do so with at least 24 hours notice, otherwise you will be charged in full for the treatment.