New Client Consultation Form

New Client Consultation Form
Name*

First NameLast Name
Date of Birth*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
If you answered YES to any of these, please explain further
What is the ethnic background of your parents? *
Do you have any medical issues?*
What is the main reason for your enquiry today?*
What is the main reason for your enquiry today?*
Hyperpigmentation (brown spots)Hyperpigmentation (white spots)Redness / RosaceaSensitivityLines (superficial)WrinkesDecreased volumeLoss of elasticity (saggy skin)Glycation (criss-cross wrinkles)DrynessBlackheadsWhiteheadsCysts (boils)Acne scarringSallow (dull/yellow) complexionOilinessOpen poresUneven skintoneFrecklesBroken capillariesInflammation
Please feel free to go into more detail
Would like to look better for my ageWould like to change something that has been botheringWould like to look more attractive
YesNo
Most daysWeeklyMonthly
DullTiredSadAngryOldFreshHappyBrightUnattractive
On a scale of 1-10, 1 being desperately unhappy and 10 being extremely happy, how satisfied are you with your appearance?
On a scale of 1-10, 1 being desperately unhappy and 10 being extremely happy, how satisfied are you with your skin?
FresherHappierBrighterMore awakeMore youthfulSlimmerMore attractiveMore illuminousMore confident
What are your skin concerns?
Do you notice your skin concern gets worse at any time of the day/month/year
What is your current routine?
Do you wear sunscreen?
How is your current skincare helping your skin?
Are there any specific products you would like to try
SkincareChemical peelsIPLMicrodermabrasionFacialsDermaplaningPigment reduction- cryotherapySkin tighteningSkin injectablesMicro- needlingMesotherapyLaserMuscle relaxant injectionsFacial fillerFacial threadsNose augmentationBrow correctionEyelid correctionFat reduction chinEar correctionCapillary removalLaser hair removalThread vain removalHair replacementLabiaplastyFat reductionBreast enlargementTummy tuckArm liftButtock augmentation
RecommendationAdvertsSearch engineSocial media
Take Photo: Front
Upload File: Front

Browse Files

Cancelof
Take Photo: Left
Upload file: Left

Browse Files

Cancelof
Take Photo: Right
Upload file: Right

Browse Files

Cancelof
POST-TREATMENT CAREAFTER YOUR TREATMENT AlumierMD skin treatments result in minimal downtime but create dramatic and visible results. However, treatments may cause the following for two to 24 hours (these are normal, expected outcomes and are not reason for concern):• Redness / Tightness / Itchiness / Sensitivity / Slight swellingSpecific treatments may cause the following for three to five days. These are normal, expected outcomes and are not reason for concern:• Temporary dryness / Skin peeling / flakingFollowing specific treatment, you will be asked to avoid getting the skin wet for eight hours.Following treatment, you will be asked to avoid makeup, self tan products, direct sun exposure, ice or ice water on the treated area and excessive heat for the rest of the day. Following treatment, you will be asked to avoid hot tubs, steam rooms, saunas, excessively hot showers, swimming and aerobic exercise for two days. Following treatment, you will be asked to avoid AHA and BHA skincare for three to five days.Following treatment, you will be asked to avoid electrolysis, waxing, threading or any other form of hair removal for seven days.Following treatment, you will be asked to avoid tanning booths, facial scrubs or mechanical forms of exfoliation, retinoic acid, laser hair removal, photofacials, chemical peels or microdermabrasion for 14 days. You will be given a Post Peel Kit, which contains SensiCalm cleanser, Hydrating Recovery Balm and Sheer Hydration Broad-Spectrum Sunscreen SPF 40 Untinted. If you have any questions regarding your treatment, don’t hesitate to contact your AlumierMD professional who will be happy to help with you further*

I have read the post care instructions and agree to adhere to them.
Reservation & Cancellation Policy for all current and future appointments: a valid credit card is required for all appointments. Please do not foget to confirm your appointment when you receive your reminder from Vagaro. In the event of cancellations received less than 24 hours prior to appointment Tues-Fri, a cancellation fee equal to the reserved service booking will incur; Saturday cancellations require 48 hour notice. No Shows will be charged 100%*

I understand the reservation and cancellation policies at Sacred Skincareapy and consent to my credit card on file being charged if I fail to give 24 hour notice for appointments scheduled Tuesday through Friday and 48 hours notice for Saturday appointments.
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 skin care professional from liability and assume full responsibility thereof.

Yes
Signature*
Should be Empty: