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

Your Journey to Radiant Skin Starts Here

Client Consultation Form

Phone number

Call us at: 770-294-3696

Our address

Visit us at: 4229 1st Ave, Tucker, GA 30085 Suite C

Client Consultation Form

Client Consultation Form

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?

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YOUR SKIN CARE

1) Have you ever had a facial treatment before?

No

Yes

If yes, please specify when

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

No

Yes

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:

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

Cleanser

Toner

Day Moisturizer

Night Moisturizer

Exfoliator

Mask

Eye Product

SPF/Sunscreen

Scrubs

Makeup Products

Soap

Shower Gels

Body Lotions

Other

10) Have you used any hair removal methods in the past six weeks?

No

Yes

Check all that apply

Shaving

Waxing

Electrolysis

Plucking

Tweezing

Stringing

Depilatories

Other:

11) What areas of concern do you have regarding your: SKIN (Check all that apply)

Breakouts/acne

Uneven skin tone

Blackhehads/whiteheads

Sun damage

Excessive oil/shine

Wrinkles/fine lines

Rosacea

Dull/dry skin

Broken capillaries

Flaky skin

Redness/ruddiness

Dehydrated

Sun/liver/brown spots

Other:

EYES (Check all that apply)

Dehydrated

Wrinkles

Puffiness

Dark Circles

Other:

LIPS (Check all that apply)

Dehydrated

Cracked/chapped lips

Other:

12) Have you ever haf an allergic reaction to any of the following (Check all that apply)

Cosmetics

AHAs

Medication

Fragrance

Food

Shellfish

Animals

Latex

Sunscreens

Drugs

New Option

Iodine

Pollen

Other:

If yes, please specify:

13) What SPF do you use on your face?

How often/when?

14) Have you recently used any self-tanning lotions, creams or treatments?

No

Yes

If yes, please specify:

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

No

Yes

If yes, please specify:

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LIFESTYLE

16) How many glasses of water do you drink per day?

less than 1 glass

1-3 glasses

4-7 glasses

8+ glasses

17) How many caffeinated beverages (coffee, tea, soda, etc.) do you consume per day?

None

1-2 drinks

3-5 drinks

6+ drinks

18) How many alcoholic beverages do you consume per week?

I don't drink

1-3 drinks

4-7 drinks

8+ drinks

19) How many hours of sleep do you get per night?

Less than 3 hours

3-5 hours

6-8 hours

8-10 hours

10+ hours

20) Which foods do you consume on a regular basis?

Fruits

Vegetables

Dairy/Eggs

Cheese

Poultry

Fish

Grains/Bread

Processed Sugar

Processed Meats

21) What does your daily commute look like?

Car

Bike

Public Transport

Walk

New Option

I don't commute

22) How often do you travel on a plane?

Never

1-2 times per year

1-2 times per quarter

Every month

Every week

23) How many hours do you spend in front of a screen or digital device?

Less than 3 hours

4-6 hours

7-9 hours

10-12 hours

12+ hours

24) Do you exercise on a regular basis?

No

Yes

25) Do you smoke cigarettes, vape, or consume other tobacco products?

No

Yes

26) What are your stress levels on a scale from 1 to 5 (1 = low stress, 5 = high stress)

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FEMALE CLIENTS

27) Are you taking oral contraceptives?

No

Yes

If yes, please specify:

28) Any recent changes to or from your contraceptive treatments?

No

Yes

If yes, please specify:

29) Are you pregnant or trying to become pregnant?

No

Yes

30) Are you experiencing any menopausal symptoms?

No

Yes

If yes, please specify:

31) Are you undergoing any hormone replacement therapy treatments?

No

Yes

If yes, please specify:

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MALE CLIENTS

32) Do you experience irritation from shaving?

No

Yes

If yes, please specify:

33) Do you experience ingrown hairs as a result of hair removal?

No

Yes

If yes, please specify:

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FUTURE APPOINTMENTS/CONTACT

May I call you at the provided number to confirm future appointments?

No

Yes

May I contact you via mail/email about future promotions and news?

No

Yes

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I understand, have read and completed this questiojnnaire 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 reveived. The treatments I receive here are voluntary and I release this institution and/or the technician/esthetician/skin care professional from liability and assume full responsibility thereof.

Client Name (Printed):

Client Signature (Signature):

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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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