Facial consult form

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Facial consult form

Full name *

Birthday

YYYY

Untitled Title

Todays date

YYYY

Phone number *

Email address *

Would you like to be added to our email list for special offers?

Yes

Clear selection

How did you hear about Meg Wheeler Esthetics?

Are you pregnant and or breast-feeding?

Option 1

Yes

Clear selection

Check all that apply:

Discoloration

Acne scaring

Uneven skin texture

Uneven skin tone

Fine lines and wrinkles

Enlarged pores

Loss of facial contours

Dilated capillaries

Lax or sagging skin

Rednesss

Acne/ breakouts

Dark under eye circles

What type of skin do you feel you have?

Dry

Normal

Combination

Oily

Clear selection

Do you have a history of acne?

Yes

Clear selection

Have you ever used Accutane?

Yes

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Do you use or have you used Retin-A

Yes

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Do you use any Glycolic acid products?

Yes

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Have you ever had a peel?

Yes

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If yes to having a peel, when was your last one?

Do you wear contact lenses?

Yes

Clear selection

Do you sunbathe or using tanning beds?

Yes

Sometimes

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Please list any medications:

Please list any allergies

Please list any conditions that could affect your treatment today.

I consent to Meg Wheeler at Meg Wheeler Esthetics to perform a facial on me that includes cleansing, exfoliation, extractions if needed, massage, masque, and product penetration. I understand that I may have allergies to products that are used. I acknowledge that I have given all information to Meg about previous services/ treatments done, any medications that can affect my skin, any medical conditions that may affect the treatment.

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Time

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