New Client Consultation Form - Facials & Skincare by Debbie

3606 E. Chapman Ave, Orange, CA 92869

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New Client Consultation Form

Today's Date *

Your Full Name *

Email Address *

Phone *

E-Giftcard Number

Date of Birth *

Your Age *

Occupation

Street Address *

Apartment, suite, etc

City

State

ZIP

How did you hear about us? *

Have you ever had a facial?YesNo

If yes, date of last treatment?

Do you currently get facials?YesNo

If yes, how often?

What do you like best, when you have facials? *

Anything you dislike?

Any specific conditions addressed with previous treatments?

Are you currently taking any prescription medications, either topical or internal? *YesNo

If yes, please list

Have you had any negative reaction to any skin care products in the past? *YesNo

If yes, explain

Have you had any cosmetic surgery on the face? *YesNo

If yes, date

Have you had Botox? *YesNo

Any injectable fillers? *YesNo

If yes, date

Do you smoke? *YesNo

Please describe your current skin care routine *

Do you:

Cleanse?Scrub?Tone?Serum?Moisturize?

Are you satisfied with your current products? *YesNoI will be recommending products that will help you achieve your goals and I will recommend the appropriate schedule for future facials.

What would you like to improve about your face? *

Do I have your permission to text or email you about your visits or specials I may have? *YesNo

I understand that for optimal results a series of treatments and using professional recommended skin care products are crucial.YesNo

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