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Client Consultation Form

Please fill out this form to the best of your knowledge. Your esthetician will use this information to determine whether there are any contraindications for your upcoming service.

First Name *

Last Name *

Email *

Phone # *

Address

Apt/Unit

City

Postal Code

Birth Month

Birth Day

Age

How did you hear about us?

Have you ever had a spa treatment before?

Yes
No

If yes, which treatments?

Do you take laxitives or diuretics?

Yes
No
Occasionally

How much plain water do you consume daily?

Do you take cleansing supplements?

Yes
No

How many alcoholic beverages do you consume weekly?

None
1-3
4 or more

How many cups of caffeine-type beverages do you drink daily?

None
1-3
4 or more

Do you take stimulants or slimming tablets?

Yes
No
Occasionally

Do you take supplements?

Yes
No
Occasionally

Have you ever experienced claustrophobia and or anxiety?

Yes
No

Do you smoke?

Yes
No

Do you follow a restricted diet?

Yes
No

Do you excerise regularly?

Yes
No

Do you have regular sleep patterns?

Yes
No

Do you use sunscreen/sunblock on your skin?

Yes
No

If yes, what SPF?

Do you burn easily in moderate sunlight?

Yes
No

Do you have a tendency to redness?

Yes
No

Do you have any special concerns pertaing to your skin?

Yes
No

If yes, please specify

Do you ever experience those conditions on your skin?

Flakiness
Tightness
Obvious Dryness

Skin type:

Oily
Combo
Dry
Sensitive
Normal

What type of skin care products are you currently using?

Soap
Toner
Masque
Cleanser
Moisturizer
Scrub/Peel
Serum
Eye Cream
Retionl/Retin-A

What type of massage do you prefer?

Light
Medium
Firm

Have you ever had a reaction to any of the following?

Cosmetics
Pollen
Animal
Medicine
Food (Seafood/Nuts)
Fragrance
Iodine
AHAs
Sunscreens
Sulphur
Essential Oils
Hair Dye
Latex
Other

If other, please specify

Are you using hormonal contraception?

Yes
No

Are you pregnant or trying to become pregnant?

Yes
No

Are you currently or within the last year under a physician's care?

Yes
No

If yes, please specify

Have you undergone surgery/X-ray within the last nine months?

Yes
No

If yes, please specify

Have you had any facial injections within the last 4 weeks? (eg. Botox, Restylane, Perlane, Hylaform)

Yes
No

If yes, where?

List any medications that you take regularly:

List any vitamins that you take regularly:

Have you had any of these health problems past or present?

Acne
Rosacea
HIV
Eczema
Psoriasis
Hepatitis
Bruises
Hemophilia
Diabetes
Herpes
Vericose Veins
Back Problem
Warts
Heart Problem
Blood Pressure Issues
Thyroid Condition
Epilepsy
Cancer
Asthma

I will inform my esthetician if I start any new medication or have any change in conditions before every facial/massage service.

I confirm to the best of my knowledge, that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. I herby absolve Adina Beauty Inc., its Directors, Employees and Associates of any responsibility for injury, loss, or damage sustained during or as a result of my treatement on its premises.

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