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Client I Facial Form

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Skin Care Consultation Form

Birthday
Day
Month
Year
Have you received a facial before
Yes
No
What type of facial treatments have you received?
Are you affected by or having any of the following:

Skin Concerns

What are your primary skin concerns? Select all that apply
How would you describe your skin type?
Do you have active acne or severe acne
Yes
No
Do you have wrinkles concerns?
What are your Pores Condition?
Do you have allergies to:
Are you allergic to Latex
Yes
No
Are you allergic to nuts, or soy products?
Yes
No
Have you ever experienced?
Have you used Accutane in the past 6 months
Yes
No
Are you currently on Acutane?
Yes
No
Have you used Retin-A or Retinoids in the past 3 months
Yes
No
Are you currently using Retin-A or Retinoids?
Yes
No
Are you currently on any medications?
Yes
No
Other
Are you?
How would you describe your overall health?
Do you suffer from ingrown facial hair?
Yes
No
Do you experience razor burns?
Yes
No
Do you use or attend any of the following practices involving heat?
What is your sun exposure?
Never
Moderate
Light
Excessive
How do you prefer to get a skin tone?
Do you experience:
What type of foundation do you wear?
How does your skin heal?
Do you bruise easily?
Yes
No
Do you smoke cannabis, tobacco, hookah or herbs?
Yes
No
Other
Do you follow a skin care routine at home?
Yes
No
Are you interested in adding new products to your current skin care routine?
Yes
No
Choice all the products you would be interested in adding to your routine?

I, confirm all information given is correct and I have properly disclosed my physical condition, condition of my skin, and known allergens for my esthetician's use.

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Serving Las Vegas, NV

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