Please complete the following so we can provide the safest, most effective and most thoughtful facial EVER 🥰

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It will allow us to spend more time on your facial instead of the consultation too.

We take your skin and this session very seriously so the more information you share the better we can prepare.

Email *

First and Last Name *

Phone # *

Are you a resident, snowbird or vacationing?

Full-time Resident

Part-time Resident

Vacationing

We love to celebrate, can we know your birthday Month and Day?

YYYY

What are your skin goals? (anything you would like to improve and maintain)

What are your skin concerns? (any issues or challenges)

If there was something you could change about your skin what would that be?

What is your routine at home?

Cleanser

Tone

Exfoliate

Serum / Concentrates / Oils

Masque

Moisturize

Eye Care

Lip Care

SPF

Body Care

Other:

What does your daily skincare routine look like? Any details are welcome.

Approximately when was your last facial treatment?

What have you liked and/or disliked about facials in the past?

At this time, does having a facial on a regular basis appeal to you?

Yes

I only like them as a treat once and a while

Other:

How do you feel about steam during a facial?

I dislike it and don't want it

I tolerate it if it will be beneficial for me

I LOVE IT!

If extractions can be included, would you like them?

Yes

Other:

Clear selection

Would you like the facial table heated

YES! I like it hot!

Maybe Low?

No, thank you :)

What would make a facial your favorite facial EVER ♡

If the treatment includes a hand massage, will this be comfortable for you?

Yes!

I think so, but let's start gentle.

No, I have an injury or arthritis.

Other:

Have you ever reacted to a product or skincare service. If so, please share details.

Rash

Irritation

Peeling

Sun Sensitivity

Breakout (surface breakouts)

Breakout (deep under the surface)

Other:

Which of the following best describes your skin type?

I. Creamy complexion Always burns easily - never tans

II. Light Complexion Always burns - tans slightly

III. Light/Matte Complexion Burns moderately - tans gradually

IV. Matte Complexion Seldom burns - always tans well

V. Brown Complexion Rarely burns - deep tan

VI. Dark Brown Complexion Rarely burns - deeply pigmented

Clear selection

What do you consider your skin type?

Dry

Oily

Normal

Combination

Sensitive

Other:

Condition of Eyes

Dehydration

Puffiness

Dark Circles

Wrinkles

Other:

Condition of Lips

Dehydrated

Cracked/chapped

Do you prefer foamy, milky or oil cleanser?

Foamy

Milky

Oil

No preference

Other:

Do you prefer a gentle or active exfoliant?

Gentle

Active

No preference

Other:

Do you prefer matte, medium or dewy moisturizer?

Matte

Medium

Dewy

Other:

Are there any aromas that you prefer or have an aversion to? Please specify below.

Check everything that you would like to address in this session?

Anti-Aging

Brightening or Hyperpigmentation

Hydration

Purification / Acne Treatment (High Frequency & Blue Light)

Sensitivity / Redness / Rosacea

Other:

Do you know if you would like any of the following enhancements? CLICK HERE to learn more about the options.

Collagen Eye or Lip Refresher

Dermaplane (will add 30 minutes)

Facial Extractions

Galvanic Current

Gua Sha Age Defying Crystal Face and Neck Massage

High Frequency

Hot / Cold Therapy

Lash Lamination aka Lash Lift (add 20-30 min)

LED (will add 20 minutes)

Liquid Lift Peptide Infusion (adds 30 min)

Microcurrent (will add 15-30 min)

Microdermabrasion (will add 15 minute)

MicroNeedling

Nano Channeling (adds 20 min)

Oxygen Mask System

Peel (may add 10 minutes)

Radio Frequency

Tinting for lashes or brows (adds 10-20 min)

Ultrasound

Waxing (adds 5-15 min)

Other:

Is there anything else you would like us to know that we have not covered here?

It is not advisable to engage in certain treatments where specific medical conditions exist or treatment occurred recently. Do you have any of the following conditions? or use medications?

If you are on any prescription medications please check with your doctor to be sure our session is safe with your medication. *

Acne topical (stop a minimum of 3 days prior)

Accutane (No microdermabasion, microneedling, dermaplaning, or peels. only gentle treatment)

Anti-Inflammatory Meds (no peels, needling, channeling and laser)

Asthma (if steam will bother you)

Blood thinner (Use caution microdermabasion or dermaplaning. No Microneedling)

Cancer, Oncology treatments or medications

Claustrophobia (if blankets, facial towel wraps, eye cover or steam will bother you)

Diabetes

Heart Condition (No microcurrent or galvanic)

Hepatitis

Cold sores/Fever Blisters/Herpes (No galvanic. Need antiviral med 1 day prior and for 5 days after any aggressive treatment/peels)

HIV/Aids (need to avoid treatments that cause wound healing response)

Hypertrophic Scarring / Keloids

Injectables (best to wait a week or two to let it settle in place before having a facial)

Metals in the body (no radio frequency, ultrasound and microcurrent depending on the location)

Pace maker (No galvanic, radio frequency or ultasound)

Photosensitizing agent products or meds (no laser, LED or IPL)

Pregnant

Retinols or Vitamin A skin treatment (discontinue for 3-14 days prior or skin reaction can occur)

Skin irritations

Anything else you feel we should be aware of, please note in "Other" space provided below

None of the above

Other:

Required

Any allergic reactions to: *

Aha's (Certain peels would need to be avoided)

Animals

Cosmetics

Drugs

Egg (no peptide firming mask)

Food - please list what under "other"

Fragrance

Iodine

Latex

Medicine

Pollen

Shellfish

Sulfa (no YonKa Juvenil)

Sunscreen

None

Other:

Required

What is your stress level

None 🥰

Off the charts 😫

Clear selection

How do you find us? *

Google

Facebook

Venice Main

Referral

Other:

If someone referred you to Self-Care Center, please share their name below so we can thank them ♡

If you have not already reserved your appointment, please CLICK HERE to do so.

You do not have to select which type of facial if you are unsure which you would like. You can select the 2nd option - 1st Facial @ HSC (new clients)

A copy of your responses will be emailed to the address you provided.

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