NAME
*
First Name
Last Name
EMAIL
*
PHONE NUMBER
(###)
###
####
CHECK ALL THAT APPLY
*
EMERGENCY CONTACT
First Name
Last Name
PHONE NUMBER
*
(###)
###
####
LIST THREE THINGS YOU LOVE ABOUT YOUR SKIN
SKIN CONCERNS & GOALS
*
CHECK ALL THAT APPLY
*
IN YOUR OWN WORDS, HOW WOULD YOU DESCRIBE YOUR SKIN?
MORNING / EVENING ROUTINE
TOP SKIN GOALS FOR THE NEXT 3-6 MONTHS
ADVERSE REACTIONS TO SKINCARE PRODUCTS OR TREATMENTS
SEASONAL CHANGES IN YOUR SKIN
AVERAGE HOURS OF SLEEP PER NIGHT
DAILY WATER INTAKE
HOW OFTEN DO YOU CONSUME DARIY, SUGAR, OR PROCESSED FOODS?
DIETARY RESTRICTIONS
SUPPLEMENTS OR REMEDIES
CURRENT STRESS LEVEL
MAIN SOURCE OF STRESS
HOW DO YOU MANAGE STRESS?
HOURS SPENT OUTDOORS WEEKLY
DO YOU WORK IN AN ENVIRONMENT WITH HIGH SUN EXPOSURE OR POOR AIR QUALITY?
HAVE YOU HAD A PROFESSIONAL TREATMENT BEFORE?
PREFERRED TREATMENT FOCUS: RESULTS, RELAXATION, OR A BLEND?
*
CONVERSATION PREFERENCE? CONVERSATION, QUIET, EITHER?
*
PREFERRED SCENTS, OILS, OR MUSIC?
LIABILITY + CONSENT
*
By checking this box, I confirm that:
I understand and accept the potential risks associated with skincare treatments, including but not limited to irritation, redness, allergic reactions, or breakout.
I acknowledge that results vary depending on my individual skin type, health, and aftercare, and no guarantees have been made regarding treatment outcomes.
I have disclosed all relevant medical conditions, medications, allergies, and skincare products I am currently using to the best of my knowledge.
I voluntarily give permission to proceed with the discussed treatment(s) and consent to have my photo taken for treatment tracking and/or marketing purposes, if applicable. (Photos for marketing will only be used with separate written consent.)
I release Skin Nourished and its staff from any liability for adverse reactions that may occur as a result of treatment or undisclosed medical information
