SPA Consultation Form | Blourin Beauty Salon

SPA CONSULTATION FORM

Client Name

Phone

Service

Questions to Review Prior to Every Service: (Circle all that apply)

What are your skin goals:

Have you started any new medication since your last visit?

Yes

No

Have you recently been tanning or suffered a sun burn?

Yes

No

Any significant changes in your skin care since your last visit?

Yes

No

Your Health

Have you experienced any of the following:

Epilepsy.

Yes

No

Varicose Veins

Yes

No

Thyroid Condition

Yes

No

Diabetes

Yes

No

Pacemaker

Yes

No

Heart Condition

Yes

No

Cancer

Yes

No

Stroke

Yes

No

Are you pregnant or trying to become pregnant?

Yes

No

Do you smoke?

Yes

No

Do you wear contact lenses?

Yes

No

Do you have metal plates/pins?

Yes

No

How many ounces of water do you drink per day?

List all medications, vitamins, and supplements you are currently taking:

Your Skin

Which products(s) are you currently using (please circle any that apply):

Do you use any products on your skin containing retinol, Glycolic Acid, Lactic Acid, or Hydroxy Acid?

Yes

No

Have you ever received a microdermabrasion, laser skin resurfacing or chemical peel?

Yes

No

Do you wear sunscreen daily?

Yes

No

Do you have a tendency toward redness?

Yes

No

Is your skin often tight, flaky, or dry?

Yes

No

Do you experience an oily shine during the day?

Yes

No

Are you prone to breakouts or acne?

Yes

No

Please list any unknown allergies or sensitives you have had to products, ingredients, animals, pollen, etc., that have caused you to react negatively:

Client Signature

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Today's Date

Month

Day

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