Sitko Skin
Client Consultation Form

登录 Google 即可保存进度。了解详情
Booking an appointment is a commitment to honoring the cancellation fee. A fee of 50% of the booked service will be charged as a non refundable deposit. If you need to cancel within 72 hours of your appointment time your deposit will not be refunded, regardless of the reason. Please keep this in mind before you book an appointment . A no show will result in a full charge of the service booked. Showing up late to your appointment will result in a modified treatment charged at full price of the service booked. If you need to reschedule your appointment it is your responsibility to do so online through the link in your confirmation email.  While our books remain closed to new clients you may not send someone in your place should you be unable to make your appointment . *
必填
Please note that you will need to reschedule if you are feeling unwell, unless you can provide proof of a negative Covid-19 test within 24 hours of scheduled appointment time. If you arrive at the studio without proof, but are exhibiting symptoms of Covid-19, you will be asked to leave and charged as a no show. *
必填
Sitko Skin is a child free environment. We service clients ages 18 and older. Please arrive to your appointment on time and alone. We are not able to accommodate more than one guest at a time. Sitko Skin is also a pet free space with the exception of emotional support animals. Due to the personal nature of self care products and services we cannot accommodate returns or refunds. All sales are final.   *
必填
Name (Last, First) *
Date of Birth *
年
/
月
/
日
Email *
Phone *
Address, City, State, Zip Code *
Occupation
Have you had a facial treatment before?
清除所选内容
Do you have any skin problems or concerns pertaining to your face & body?
Which of the following best describes your skin type?(Please check one)
Have you ever had chemical peels, laser treatments, or microdermabrasion? If yes, When was your last treatment?
Do you use any topical or internal products like Accutane, Retin A, Renova, Adapalene Hydroxyl Acid or any other Retinol/Vitamin A derivative products
清除所选内容
If yes, please specify these products:
Are you or have you used any topical creams, lotions or oral antibiotics for acne, cancer, anti-aging or hyperpigmentation?
清除所选内容
If your answer is yes, please specify:
Do you take any medications that cause a light sensitivity?
清除所选内容
If so, please include more info:
Have you had any of the following injectables or cosmetic surgeries/procedures?
How long ago was your last injection?
Have you used any hair removal methods in the past two weeks?
清除所选内容
Do you experience irritation from shaving?
清除所选内容
Do you experience ingrown hairs as a result of hair removal?
清除所选内容
Do you have hyperpigmentation (darkening of the skin) or hypopigmentation (lightening of the skin) or get marks after physical trauma?
清除所选内容
If yes, please describe in more detail:
Do you form thick or raised scars from cuts or burns?
清除所选内容
What areas of concern do you have regarding your skin? (Check all that apply)
What areas of concern do you have regarding your eyes?
What areas of concern do you have regarding your lips?
Have you ever had an allergic reaction to any of the following?
Have you recently been in a tanning bed, had sun exposure, or used a self-tanning lotion, cream or any product that would alter the color of your skin?
清除所选内容
Healthy History Questions
Are you taking any oral contraceptives?
清除所选内容
If yes, please specify:
Have you experienced any recent changes to or from your contraceptives?
清除所选内容
If yes, please specify
Are you pregnant, breast feeding or trying to get pregnant?
Are you experiencing any menopause symptoms?
Are you currently undergoing any hormone therapy treatments?
Do you have a history of or have any of the following?
Do you have a history of skin cancer?
Lifestyle Questions
How many glasses of water do you drink daily?
How many caffeinated beverages (coffee, tea, soda, etc.) do you consume daily?
How many alcoholic beverages do you consume per week?
How many hours of sleep do you get per night?
Which foods do you consume on a regular basis?
How often do you travel on a plane?
How many hours daily do you spend in front of a screen or digital device?
Do you exercise on a regular basis?
清除所选内容
Do you smoke cigarettes, vape or consume tobacco related products?
清除所选内容
Do you swim in a chlorinated pool for exercise or soak in a jacuzzi?
清除所选内容
Are you claustrophobic?
清除所选内容
What are your stress levels on a scale from 1-5?
清除所选内容
Are you comfortable with your before/after photos being shared on social media?
清除所选内容
What skincare products are you currently using?
Which skin care products are you interested in adding to your regimen?
Is there anything else you would like me to know?
COVID-19 Information & Liability Waiver
Have you had a fever in the last 24 hours of 100°F or above? *
Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, shortness of breath, diarrhea? *
Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms? *
COVID-19 is a highly contagious virus that spreads from person to person. In addition to long-held and explicit sanitation measures we have always adhered to, new preventative measures have been put in place to further reduce the spread of this novel coronavirus. However, these best practices still offer no guarantee regarding your potential risk of being infected.
I understand that because the practice of esthetics involves maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. By signing this form, I acknowledge that I am aware of the risks involved from receiving treatment at this time. I voluntarily agree to assume those risks, and I release and hold harmless the practitioner/business from any claims related thereto. I give my consent to receive treatment from this practitioner. *
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosure. 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 here are voluntary and I release this institution and/or the technician/esthetician/skincare professional from liability and assume full responsibility thereof. *
How did you hear about us?
提交
清除表单内容
切勿通过 Google 表单提交密码。
此内容不是由 Google 所创建，Google 不对其作任何担保。 举报滥用行为 - 服务条款 - 隐私权政策
Google 表单