Facial Consultation Form

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
Wrikles
Oily T Zone
All Over Oilyness
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 recieved. The treatments i recieve here are voluntary and i release this institution and/or skin care professional from liability and assume full responsibility thereof.