0
  • No products in the cart.
Total:$0.00
 

Facial Consultation Form

Esteem Hair Beauty Spa Pre Facial Consultation Form

Please Complete this prior to your facial treatment

Fullname

Mobile Number

E-mail Address

Have you ever had a facial before?

Yes
No

Please tick if any of the following have previously or currently apply

Currently Pregnant
Injuries
Using Vitamin A
Using Glycolic
Using AHA / BHA
Botox
Fillers
Currently Breast Feedin
Using Retin-A
Cold sores
Menopause
Currently Sunburnt
Metal Braces or Fillings
Contraception Pill
HRT
Known Allergies

Please list any Medication Or Vitamins Your currently taking

Which of the following best describes your skin type (Tick as many as you like)

Sensitivity
Dryness
Itchy eyes
Redness
Rosacea
Flaking
Dehydration
Dull
Fine Lines
Wrinkles
Oily T Zone
All Over Oiliness
Open Pores
Whiteheads
Blackheads
Pustuals
Facial Hair
Broken Capillaries
Underlying Congestion
Freckles
Age Spots
Always Burns Easily Never Tans
Always Burns Tans Slightly
Burns Moderately Tans Gradually
Seldom Burns
Always Tans Well
Rarely Burns Deep Tan
Never Burns, Deeply Pigmented

Dark Circles Around Eyes

 

What are your skincare goals?

What is your Skincare routine?

Cleanse
Tone
Moisturise
Exfoliate
Mask

None of above

 

What would you like to achieve from this treatment?

Have you ever had any chemical peels, laser or microdermabrasion

Have you ever had any chemical peels, laser or microdermabrasion

Any other concerns or requests?

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 institution and/or skin care professional from liability and assume full responsibility thereof.

Submit     |   Reset