Client Consultation Form

Date *

Name *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Mobile Phone *

Birth Date *

What would you like to achieve from your treatment today? *

Your Skincare History

Have you ever had a facial service before? *

Yes
No

When? *

Do you have any medical skin conditions or concerns pertaining to your face or areas to be treated? *

Yes
No

Please specify: *

Have you ever had an advanced esthetic service such as a chemical peel, microneedling, dermaplaning, microcurrent, or laser treatment? *

Yes
No

If yes, which treatments and when? *

How would YOU describe your skin? (ex: oily, dry, normal, combination, a daily battle?) *

What skin care products are you currently using? (Please list brand names where known)

Facial Cleanser

Yes

Brand if known

Toner

Yes

Brand if known

Mask

Yes

Brand if known

Eye Product

Yes

Brand if known

SPF

Yes

Brand if known

Day Moisturizer

Yes

Brand if known

Night Moisturizer

Yes

Brand if known

Serum

Yes

Brand(s) if known

Exfoliant

Yes

Brand if known

Make-up

Yes

Brand if known

Body Scrubs

Yes

Brand if known

Body Wash/Soap

Yes

Brands

What areas of concern do you have regarding your:

SKIN (Please check any that apply and describe)

Describe any areas of concern about your SKIN that you checked above:

EYES (Please check any that apply and describe)

Describe any areas of concern about your EYES that you checked above:

LIPS (Please check any that apply and describe)

Dehydrated
Cracked/chapped lip
Other (describe below)

Describe any areas of concern about your LIPS that you checked above:

Have you ever had an allergic reaction to any of the following? (Please check any that apply and describe the reaction below..)

Describe any allergic reactions checked above:

Have you ever had an adverse reaction after using a skincare product? *

Yes
No

If yes, check and describe below *

Describe any allergic reactions checked above:

Are you interested in learning more about natural restorative/anti-aging services (with no sales pressure)? *

Yes
No

Have you traveled recently? (copy) *

Yes
No

If yes, when and where?

Melissa Williams

Melissa Williams

Melissa Williams

Your Skincare History

Melissa Williams, Master Esthetician