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Total Body Care Skin Consultation Form
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First Name
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Email Address
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Morning Regime
Weekly Treatments
Evening Regime
Special Treatments
What are you currently using or doing and how has that been working?
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What would you like to change about the results that you are currently receiving?
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Your Treatment Goals
Specific Results
A Relaxing Experience
Both
What would you like from this visit?
Product to take home
One time service
On-going treatment
Favorite Treatments
Body Care
Facials
Make Up
Manicures / Pedicures
Massages
Waxing
Treatment Length and Detail
Express (Clinical) 30 - 50 minutes
Pampered 60 - 75 minutes
Make up Foundation Coverage
Sheer
Medium
Full
GREATEST MAKE UP CHALLENGE
Eye Shadow
Cheek
Foundation
Brows
Lashes
Lips
Highlighting and Contouring
DESIRED MAKE UP LOOK
Day
Party
Formal
Night
Natural
Smoky
SKIN TYPE
Very Dry Skin
Dry Skin
Combination
Very Oily
Oily
Sensitive
Acne
PLEASE SELECT CONCERNS
Flakiness / Dry Skin: Face or Body
Dull skin
Neck Creases
Sagging Neck
Enlarged Pores
Clogged Pores
Excess Oil
Razor Bumps
Blackheads face or back
Breakouts: face , back or bikini Line
Pigmented spots
Aging skin
Redness
Visible Capillaries
Muscle Tension, Soreness or Weakness
Hand / Nail Condition (roughness, dryness, hangnail)
Foot / Nail Condition (cracked, calloused, thickened)
ALLERGIES
MEDICATIONS
Do you have any health problems or concerns that we need to be aware of before we begin?
Have you had an adverse reaction to a skin care treatment or cosmetic product or ingredient? If yes, describe.
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Are you pregnant or lactating?
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no
Do you currently wear contact lenses?
yes
no
Do you smoke?
yes
no
Have you taken Accutane® within the past 12 months?
yes
no
Have you used Retinol®, Retinol-A®/Renova® or alpha hydroxy acids within the last 6 months?
yes
no
Have you had a medical peel or ANY other medical treatment within the past 6 months?
yes
no
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