Skin Consultation Survey Page

Skin Consultation Survey

Hello, dear customer. In order to proceed with your free consultation, I'll first need to know a little about you and your skin. After answering the form, you'll be redirected to the site of booking and will receive my contact by email, confirming that your form has been sent and received.

Your name:

Date of Birth:

Address:

Home Phone:

Cell Phone:

E-mail address:

Does your job require that you work outdoors?

Yes No

Referred by:

What would you like to achieve from your treatment today?

What are your skin care goals?

If your challenge wasn't mentioned above, write down what they are below:

Have you ever had a facial or skin treatment before? When?

Please feel free to go into more detail:

If you are seeking corrective treatments, please detail the SPECIFIC products (BRAND & PRODUCT TYPE NAME) you are currently using so I can best answer any questions on ingredients and help you meet your skin care goals:

Please specify which product or type, if you answered 'Yes, currently using' to above:

If checked, please note last time:

Have you ever received chemical peels, laser services, or microdermabrasion treatments?

Yes, within the last month. Yes, within the last 2-3 months. No.

Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks?

Yes. No.

If you checked yes to any of these, please provide further information. If not mark NA:

If other, please list:

If Other, please specify:

Have you used or been prescribed any medications (topical or oral) for acne/acne control?

Yes. No.

If yes, please specify what and date last used:

Are you a smoker?

Yes. No. Social.

Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)

Yes. No.

Have you ever experienced claustrophobia?

Yes. No.

Please rate your stress level:

Low. Mediu. High.

Please let me know if you would like to learn about natural ways to lower stress levels.

Yes. No.

FEMALE CLIENTS Are you taking birth control?

Yes. No. NA

If yes, what kind:

Any recent changes to or from your contraceptive treatment?

Yes. No,

If so, what and when:

Are you pregnant or trying to become pregnant?

Yes. No.

Are you lactating?

Yes. No.

Any menopause problems?

Yes. No.

If yes, please specify:

Are you undergoing any hormone replacement therapy?

Yes. No.

If yes, please specify:

MALE CLIENTS What is your current shaving system?

Razor Wet shave Electric NA

Do you experience irritation from shaving?

Yes. Ingrow hairs. No.

If yes, please explain:

What SPF do you use on your face? How often/when?

Have you had any recent tanning bed or sun exposure that changed the colour of your skin?

Yes. No.

If yes, specify:

Have you experienced Botox, Restylane, or Collagen injections?

Yes. No.

If yes, specify:

Female Clients Only Are you taking oral contraceptives?

Yes. No.

If yes, specify:

Which of the following best describes your skin type?

I Creamy complexion Always burns easily, never tans. II Light Complexion Always burns, tans slightly. III Light Matte Complexion Burns moderately, tans gradually. IV Matte Complexion Seldom burns, always tans well. V Brown Complexion Rarely burns, deep tan. VI Black Complexion Never burns, deeply pigmented.

Future Appointments/Contact

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 institution and/or skin care professional from liability and assume full responsibility thereof.

Location

15 Station Rd, Cookham, Maidenhead SL6 9BR

Contact

+44 07886 364844
Dkuhnbeauty@gmail.com

Hours

Mon – 9:30am | 8pm

Tue – 9:30am | 8pm

Wed – 9:30am | 8pm

Thu – 9:30am | 8pm

Fri – 9:30am | 8pm

Sat – 11am | 6pm

Stay updated

Contact

+44 7365-491122
Dkuhnbeauty@gmail.com

Hours

Mon – 9:30am | 8pm

Tue – 9:30am | 8pm

Wed – 9:30am | 8pm

Thu – 9:30am | 8pm

Fri – 9:30am | 8pm

Sat – 11am | 6pm

Location

15 Station Rd, Cookham, Maidenhead SL6 9BR

Stay updated

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