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THE COMPACT FORM The Only Consultation Form You'll Ever Need

STANDARD QUESTIONS

What is your name?

Email address?

Phone number?

Date of birth?

Emergency Contact Name? Relationship to you? Phone number

SKINCARE QUESTIONS

What changes are you hoping to see in your skin?

How would you describe your skin?

  • Oily
  • Sensitive
  • Dry
  • Normal
  • Combination

Do you have concerns about any of the following?

  • Acne Scarring
  • Acne/Breakouts
  • Blackheads
  • Broken Capillaries
  • Dark Under Eye Circles
  • Dehydrated
  • Discoloration
  • Dry Skin
  • Enlarged Pores
  • Fine Lines and Wrinkles
  • Hyperpigmentation
  • Ingrown Hairs
  • Keloids
  • Loss of Facial Contours
  • Oily Skin
  • Redness
  • Rosacea
  • Sun Damage
  • Sun Spot/Liver Spot/Brown Spot
  • Whiteheads
  • None of the Above

Have you ever received the following procedures?

  • Body treatments
  • Botox®
  • Chemical Peels
  • Collagen Injections
  • Cosmetic Surgery
  • Dermaplaning
  • Electrolysis in the past 14 days
  • Enzyme Treatments
  • Esthetic Laser Treatment (IPL, Fraxel, etc.)
  • Eyelash/Brow Tinting/Permanent Makeup
  • Facials
  • Facial Ultrasound
  • Facial Waxing/Threading/Microblading
  • Home Care With Acids
  • Laser Hair Removal
  • LED Treatment
  • Microdermabrasion
  • Microneedling
  • Platelet-Rich Plasma (PRP)
  • Radio Frequency (RF) Treatments
  • Restylane®
  • None of the above

How often do you have these procedures done? And, when was the last time?

Have you used any of the following topical/oral dermatological medications?

  • Accutane
  • Alpha Hydroxy Acids (Glycolic, Lactic, Malic)
  • Avage
  • Benzol Peroxide
  • Beta Hydroxy Acid (Salicylic)
  • Differin
  • EpiDuo
  • Hydroquinone
  • Renova
  • Retin-A
  • Tazarac
  • Topical Antibiotics
  • Trentinoin
  • Ziana
  • None of the above

How often do you apply/take these medications? Or when was the last time you applied or took them?

Which products do you use daily or at least once per week?

  • AM Moisturizer
  • Chemical Exfoliator
  • Cleanser
  • Corrective Serum
  • Eye Cream
  • Facial Scrub
  • Makeup
  • Mask
  • PM Moisturizer
  • Soap
  • Sunscreen
  • Toner

Please list the brand(s) you use regularly.

Please select any and all that apply to you:

  • Claustrophobic
  • Wear Contact Lenses or Glasses
  • Sunbathe or Use Tanning Beds
  • Have had excessive sun exposure in the last few days
  • Plan on having excessive sun exposure in the near future
  • None of the above

Please list any allergies you have.

An Overview of Your Medical History

Are you currently receiving treatment from a doctor or specialist?

[If Yes] Please explain the relevant details of your treatment(s).

Are you taking any medication, supplements or herbal remedies?

[If Yes] Please list name and other relevant details of what you're taking:

Are you currently pregnant?

[If Yes] How many months/weeks pregnant are you?

Please select any and all that apply to you.

  • Nursing/Lactating/Breastfeeding
  • Currently using or have used Roaccutane in the last 6 months
  • Currently have a skin infection/open wound in the treatment area
  • Currently taking oral contraceptives/birth control
  • Currently experiencing Perimenopause or Menopause
  • Currently undergoing hormone therapies or taking infertility drugs
  • None of the above

Do you smoke or drink alcohol?

[If Yes] How many units per day? How often?

Please indicate if you are dealing with or have dealt with any of the following conditions:

  • Acne
  • Albinism/Vitiligo
  • Arthritis
  • Asthma/Bronchitis
  • Bell’s Palsy
  • Blood Disorders
  • Bruises
  • Cold Sores/Fever Blisters
  • Constipation
  • Convulsions
  • Cut/Abrasions
  • Depression
  • Diabetes
  • Eczema
  • Epilepsy/Blackouts
  • Fibroids
  • HIV
  • Heart Issues
  • Hepatitis
  • Jaundice/Hepatitis
  • Lupus
  • Melanoma
  • Melasma
  • Moles
  • Pacemaker/Metal Implants
  • Polycystic Ovarian Syndrome (PCOS)
  • Psoriasis
  • Scar Tissue (Within 6 months)
  • Severe Headaches/Migraines
  • Skin Disorders/Diseases
  • Stomach Ulcers
  • Sunburn
  • Thyroid Issues
  • None of the above

Diet and Health Overview

What specific foods do you eat almost daily or most days of the week?

How much water do you drink daily?

How many hours of sleep do you receive per night/day?

Do you have at least one bowel movement per day?

Are there other aspects of your health or medical history that you think we should know about?

[If Yes] Please share those details.

What treatment are you having today?

[Specific Consent Forms For Various Treatments Can Be Inserted Here]

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. I consent to the data being collected.

Please type your name to indicate you understand the aforementioned terms of the consent you have agreed to. Your typed name will serve as your signature.

Today's Date?

Thank you so much for your time and for the important information you provided.