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HOME
ABOUT
SERVICES
LE BEAU JOLIE
PAYMENT PLANS
CONTACT US
RESOURCES
Client Consultation Form

Your Journey to Radiant Skin Starts Here

Client Consultation Form

Phone number

Call us at: 01234 567890

Our address

Visit us at: 123 Beauty Lane, London, UK

Contact form

Client Consultation Form

2) Have you ever had a body spa treatment before?

No

Yes

Name

Date of Birth

Address

Phone

Email

Sex

Female

Male

How were you referred to us?

Occupation

Does your job require that you work outdoors?

Yes

No

What would you like to achieve from your treatment today?

Free Text

Your Skin Care

1) Have you ever had a facial treatment before?

No

Yes

If yes, please specify when

If yes, please specify when

3) Which of the following best describes your skin type? (Please check one)

Type I - Fair skin tones - Always burns, never tans

Type II - Light skin tones - Burns easily, tans slightly

Type III - Fair to olive skin tones - Burns moderately, tans moderately

Type IV - Light brown skin tones - Burns slightly, tans easily

Type V - Dark brown skin tones - Rarely burns, tans easily

Type VI - Dark brown to black skin tones - Never burns, tans easily

4) Do you have any special skin problems or concerns pertaining to your face or body?

No

Yes

If yes, please specify:

5) Have you ever had chemical peels, laser treatments, or microdermabrasion?

No

Yes

In the last month?

No

Yes

6) Do you use Accutane, Retin-A, Renova, Adapalene Hydroxyl Acid or any other Retinol/vitamin A derivative products?

No

Yes

If yes, please specify what and when last used:

7) Have you used acne medication?

No

Yes

If yes, when?

Which medication?

8) Have you experienced Botox, Restylane, or collagen injections?

No

Yes

If yes, please specify:

9) What skin care products are you currently using? (List brands if known)

Free Text

9) What skin care products are you currently using? (List brands if known)

Cleaner

Toner

Day Moisturizer

Night Moisturizer

Exfoliator

Mask

Eye Product

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Phone Number

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Locate Us

Opulence Wellness & Med Spa
4229 1st Ave., Tucker, GA Suite C
10am - 6pm Appt Only

info@opulencemedicalspa.com

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