New client form | Spatacular Skin

First name

Last name

Address

Birthday

Month

Day

Year

Email

Phone

How did you hear about us?

Friend - Referral Name

Google

Social Media

Other

What are your skin concerns?

Firm Skin/Anti-Aging

Smooth skin/Refine Texture

Clear Skin/Acne

Brighter Skin/Hyperpigmentation or Sun Damage

Do you consider your skin sensitive (including redness, stinging, itching, extreme dryness)?

No

Yes

When exposed to the sun, do you...

Please check with products you are currently using at home.

How much time are you willing to spend on your skincare routine?

Morning

Evening

Both

Where do you purchase your skincare products?

Are you currently using any prescription topical acne or rosacea medications?

No

Yes

Do any of your skincare products contain Retin-A, Glycol Acid, Salicylic Acid, BHA, AHA

No

Yes

Are you currently happy with your skincare products?

No

Yes

If you wear makeup, what type do you use?

Liquid Foundation

Mineral Makeup

Tinted Moisturizer/SPF

Powder

Where do you purchase your skincare products?

Spa/Salon

Ulta/Sephora

Online

Stores

Have you ever received a professional skincare treatment before? If so, which ones?

Have you been exposed to the direct sun in the last 10 days?

No

Yes

Do you suntan or use a tanning booth? If so, how often?

Do you have any environmental, drug or food allergies?

No

Yes

What type of work do you do?

Please rate your stress level from 1-5, with 5 being the highest.

Within the last year, have you been under the care of a physician (excluding a yearly physical)?

No

Yes

If yes, please explain.

Please check if you've had (or currently have) any of the following.

Please list any medications and supplements you are currently taking.

Female Clients:

Pregnant or Nursing

On Hormone Therapy

Presently Taking Birth Control

Not Applicable

Signature

New Clients