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Skincare Consultation -Form Fill

Section One
Q1

Date*

Month
Q2

Date*

Day
Q3

Date*

Year
Q4

Name*

First Name
Q5

Name*

Last Name
Q6

Date of Birth*
Q7

Address*

Street Address
Q8

Address*

Street Address Line 2
Q9

Address*

Barangay
Q10

Address*

City
Q11

Address*

Province
Q12

Address*

Country
Q13

Mobile Number*

Area Code
Q14

Mobile Number*

Phone Number
Q15

E-mail*
Q16

Occupation *
Q17

How did you hear about us?*
Q18

If Referral, please list name
Q19

If Other, please let us know
Q20

Preferred Branch*
Q21

What are your skin care goals?*
Q22

What are your skin care challenges?*
Q23

Please feel free to go into more detail
Q24

Have you ever had a facial or skin treatment before?*
Q25

If Yes, when?
Q26

What Skin Care Products do you currently use?*
Q27

Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?*
Q28

Please specify which product or type, if you answered 'Yes, currently using' to above.
Q29

Have you received any of these hair removal services in the last 30 days?*
Q30

If checked, please note last time.
Q31

Have you ever received chemical peels, laser services, or microdermabrasion treatments? *
Q32

Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks?*
Q33

Have you experienced any of these health conditions in the past or present?*
Q34

If you checked YES to any of these please provide further information. If not mark, NA*
Q35

Do you?*
Q36

Do you take any of the following dietary / health supplements?
Q37

If other, please list
Q38

Any known allergies?*
Q39

If Other, please specify
Q40

Have you used or been prescribed any medications (topical or oral) for acne / acne control?*
Q41

If yes, please specify what and date last used
Q42

Are you a smoker? *
Q43

Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)*
Q44

Have you ever experienced claustrophobia? *
Q45

Please rate your stress level*
Q46

Are you taking birth control? *
Q47

If yes, what kind
Q48

Are you pregnant or trying to become pregnant?*
Q49

When was your last period? *
Q50

Any menopause issues? *
Q51

If yes, please specify
Q52

Are you undergoing any hormone replacement therapy?
Q53

Post Facial Care/Waxing Instructions: Aerobic exercise and/or vigorous physical activity should be avoided for 48 hours. Direct sunlight exposure is to be avoided immediately following the treatment (including any strong UV light exposure and/or tanning beds). If some sun exposure cannot be avoided first apply a broad spectrum sunscreen of SPF 30. Sunscreen (with a minimum SPF 15) should become part of your daily skin care regimen as skin can potentially become more sensitize to the sun as a result of this treatment. Unless otherwise specified, in the evening following your treatment, cleanse your skin with a mild cleanser and water followed by a non-active moisturizer. Do not apply additional exfoliating ingredients/products the day of your service as over-exfoliation can result in irritation or further sensitivity. Consult your skin care professional before resuming topical treatments. Enzyme peels, DermaFile or DermaDisc treatments, chemical peels or facial waxing can result in skin flushing/redness or slight skin flaking or sensitivity for up to 48-72 hours post treatment. DO NOT peel, pick, rub, or scratch your skin at any time, whatsoever. This can potentially cause damage or compromise your results.*
Q54

Online Consultation Reservation and Cancellation Policy: 1. A Non-Refundable Online Consultation Fee of P500 is required, but deductible upon your payment at the clinic during actual servicing. 2. Cancellations or no show until the day of the appointment may be rebooked upon advice of the client, however will be subject again to Patient Evaluation and Triaging and schedule availability. 3. In the event of a second cancellation or no show, only 50% of Online Consultation Fee will be deductible. 4. In the event of a third cancellation or no show, the full amount is waived.*
Q55

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 disclosures. 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 skin care professional from liability and assume full responsibility thereof.
Q56

Signature*