Facial Consultation Form Please enable JavaScript in your browser to complete this form.Name *FirstLastPhone NumberEmail *LocationAge Gender FemaleMaleEthnicity Are you Pregnant?YesNoAre you planning a pregnancy in the near future?YesNoAre you currently Nursing? YesNoDo you have regular periods? YesNoAre you using birth control? If so, what kind?Please list any topical or internal medication you are currently using Are you currently, or have you previously experienced any of the following:Heart conditionPacemakerHeadachesAnemiaCancerThyroid conditionKidney problemsHigh blood pressureArthritisAsthmaDiabetesHerpes simplexAIDS/HIV POSITIVEOTHERHow many bowel movements do you have a day? 12+once a week What is your current AM Regimen? Please be specific and list productsWhat is your current evening routine? Please be specific and list productsAre you using Daily SPF? If so, what kind?Are you using Makeup? If so what kind?Please list any additional products that you use including peels, masks, enzymes and/or weekly treatments?Please list products you are running low on and/or want to replace?What are your skincare goals? Do you shave your face? if so, what kind of razor do you use? Do you use shaving products? If so, what kind?Do you have any allergies? Also list any skin treatment products you have used that caused an unexpected reaction or side-effect: What is your Skin type?OilyCombinationNormalDryI'm not sureWhat are your skincare Concerns?Age spotsBlackheadsBroken CapillariesBumpsCystsDark spotsDehydrated SkinDry, Flaky SkinFine Line/ WrinklesMiliaOily SkinPimples/ PustulesRazor BumpsShaving IrritationPlease indicate if you have ever used any of the following medications for skin treatment: SulfurAccutaneRetin AGlycolic AcidSalicylic AcidLactic AcidTazorateneCortisoneClindamycinBenzoyl PerocxideWhat condition were you treating with this medication(s)? When was the last time you used these medications?Check the box, if yes.Have you been Diagnosed with Rosacea?Do You smoke?Are you currently under stress?Do you use Fabric Softener or Dryer sheets?Average hours of sleep?How often do you exercise?Please list all supplements, vitamins, energy bars, protein drinks that you take.Do you regularly eat or ingest:KelpSeaweedSushiFast foodsSaltMilk/and or cheesepeanuts or peanut butterSupplements, vitamins, or drink powdersSugary foodsSimple carbs (pasta, sugar, sweets)How much water do you drink per day?What is your skincare budget for 3 months60-100100-200200+How did you hear about us?Friend/relativeInstagramFacebookGoogleOtherIs there anything else you feel I should know?Photographs relating to my case, may be published and/or republished, either separately or in connection with each other, in professional journals, medical books, social media, skin care magazines, slides, or used for any purpose which he/she may deem proper in the interest of medical education, knowledge, or research, provided, however; it is specifically understood that in any such publication or use I shall not be identified by name( unless given permission).I agreeI disagreeI certify that the above information is correct to the best of my knowledge. In accordance with the law, Air of Earth Aesthetics cannot cure, treat, prevent or diagnose any condition. These treatments are used as regimens for improving skin appearance and wellness. Information exchanged during any session should be given at my own discretion. Because certain esthetics treatments should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the skin care therapist updated as to any changes in my health prior to any future sessions and understand that there shall be no liability on the therapist’s part. The therapist reserves the right to refuse service to anyone for any reason. I fully understand that the therapist performs her services within the parameters of esthetics, using skin care treatments and therapies. I fully understand that the esthetics therapist is not an allopathic doctor, dermatologist, or psychiatrist and does not portray himself/herself to be. If I experience any pain or discomfort during the session, I will immediately inform the therapist so that the products and/or techniques may be adjusted to my level of comfort. By signing below I acknowledge that I have read and understand all parts of this consent/intake form, and that I have had the opportunity to ask any questions with regard to any services or therapies offered. All client information is confidential. *Date *EmailSubmit
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