Client Facial Questionnaire - Retreat Spa & Salon

Phone

This field is for validation purposes and should be left unchanged.

Contact Info

Name*

Age

Email*

Phone*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

What do you currently use to cleanse your face?*

What do you currently use to moisturize?*

Special treatments?

Eye creme, night creme, masks, etc.

What improvements would you like to see on your face?*

Are you pregnant?*

Are you taking Accutane?*

Do you wear contact lenses?*

Do you have Rosacea?*

Current medication(s)

Are you using any topical medications?

If so, please list here, otherwise leave blank.

Are you using Retinoids?

If so, please list here, otherwise leave blank.

Are you using Exfoliating Acids?

If so, please list here, otherwise leave blank.

Do you have any inplants?

Pacemaker, pins in bones, etc. If so, please list here, otherwise leave blank.

Have you undergone treatment from a Dermatologist?

If so, what condition? Leave blank if no.

Have you ever had an adverse affect to a cosmetic product?

If so, what happened with which product? Leave blank if no.

Conditions

Please select all that apply.

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