Client Consultation Form  
Please complete to the best of your abilities and I will be  in touch to book you in for your consultation  
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Full Name *
Date of Birth *
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Phone Number *
Address *
Email *
In case of emergency: *
Your Skin Goals and Concerns: *
What skincare and makeup products are you currently using? *
Does your job and lifestyle require that you work/play outdoors? *
Do you wax your face on a regular basis? *
If yes when was the last time you waxed?
Have you ever had facials, chemical peels, microdermabrasion, or any resurfacing treatments? *
If yes, was it within the last month? *
If yes what procedure did you have:
Are you using? Retin-A *
Are you using? Benzoyl Peroxide? *
Tell me about any allergies or sensitiveness you have: *
Have you ever experienced a reaction to any of the following? *
Required
When was your most recent dental work and what procedure: *
Do you use Botox/Fillers, if so when was your last treatment: *
Tell me about any health issues you have: *
Please tick if any of the following apply *
Required
Tell me about any medications you take: *
Required
I have read and completed this questionnaire truthfully. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive are voluntary and I release the company and/or skin care professional from liability. *
Required
Date *
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