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Skin Sense Studio
Shop Skincare
Home
Services
Skin Care
Lashes & Brows
Waxing
About
About
Forms
Spa Policies
Book Now
About
About
Forms
Spa Policies
Client Consultation Form
Name
*
First Name
Last Name
Email Address
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
How did you hear about Skin Sense Studio?
*
Date of Birth
*
MM
DD
YYYY
General Health Info
Any Known Allergies?
*
Latex
Aspirin
Shellfish
Iodine
Food
Other
None
Are you currently being treated by a physician for any conditions?
*
Yes
No
Please list medications currently taking:
*
Please list any surgeries in the past year:
*
Do you have an metal implants or a pacemaker?
*
Yes
No
Do you use a tanning bed?
*
Yes
No
Do you use sunscreen daily?
*
Yes
No
How many hours do you sleep at night?
*
Are you claustrophobic?
*
Yes
No
Are you pregnant or nursing?
*
Yes
No
Skin Info
Please check all concerns:
*
Dark spots
Uneven skin tone
Acne breakouts or congestion
Wrinkles or fine lines
Facial hair
Body hair
Thin or misshaped brows
Redness or Rosacea
Lack of skin tone (firmness)
Stress
Cellulite
Rough skin or Keratosis Pillaris
Dry skin
Sensitive skin
Dullness
Dark circles under eyes
Puffiness under eyes
Have you ever had a facial treatment before?
*
Yes
No
If yes, how long ago?
What would you like to accomplish with your treatment?
*
Do you cleanse your skin morning and night?
*
Yes
No
What products do you use?
*
Please list any toners, exfoliants, masques, serums, moisturizers, or other topicals that you apply daily:
Do you enjoy spending time on your skin routine, or do you prefer a very simplified apporach?
Do you burn easily in the sun?
*
Yes
No
Do you get an oily shine throughout the day?
*
Yes
No
Would you consider your skin to be:
*
Oily
Dry
Normal
Sensitive
Do you prefer a facial...
*
that incorporates a lot of massage and stress therapy?
that is a simple skin treatment?
Do you prefer organic products?
*
Yes
No
Treatment Info
Do you prefer a heated treatment bed?
*
Yes
No
Are you sensitive to fragrances or essential oils?
*
Yes
No
Do you prefer massage pressure:
*
Mild
Moderate
Firm
Do you have any other concerns or questions not listed?
When was your last chemical peel or skin resurfacing treatment?
*
Are you currently using a prescription Retin A product?
*
Yes
No
Consent for treatment
I give my permission for Melissa Bingham/Skin Sense Studio to treat me today. I have disclosed any allergies, current medical conditions that I am being treated for and release Melissa Bingham/Skin Sense Studio of any liabilities that may arise during my treatment. If my treatment is ongoing, I will disclose new allergies, medical conditions or medications at the time of my service.
*
Thank you!