FACIAL CONSULT FORM

All services include 10 minutes for dress time / consultation. Its very imortant to arrive early and start appointmnets on time to avoid cutting into your service time.

How did you hear about Wine & Unwind Day Spa?!
YOUR HEALTH
Within the last year, have you been under a dermatologist’s or other physician’s care?
List any medications, supplements, vitamins, diuretics, slimming pills, Isotretinoin, etc. That you take regularly.
Do you smoke?
Do you exercise regularly?
Do you follow a restricted diet?
Do you wear contact lenses?
Do you have metal implants, a pacemaker or body piercing?
Rate your level of stress on a scale of 1 to 5 (1= low stress, 5= high stress)
Do you have allergies?
If yes, please explain.
Do you sunbathe or use tanning beds?
Do you drink more than 4 caffeinated beverages daily (coffee, teas, soft drinks)?
YOUR SKIN

What are your specific concerns/challenges with your skin?
What face and body skin care products are you currently using?
Have you ever had chemical peels, microdermabrasion, or any resurfacing treatments?
If yes, in the last month?
Do you use Retin-A, Renova, Adapalene or any other prescription drug?
If yes, was it within the last 3 months?
Are you currently using any products that contain the following ingredients?*glycoIic acid *lactic acid *any exfoliating scrubs *any hydroxyl product *Vitamin A derivatives (i.e., Retinol)
If yes, please explain.
Do you ever experience these conditions on your skin? *flakiness *tightness *obvious dryness
What SPF sunscreen do you use on your face? Body?
Do you burn easily in moderate sunlight?
Do you have a tendency to redness?
Do you suffer from sinus problems?
Do you ever experience burning, itching or stinging sensations on your skin?
FEMALE CLIENTS ONLY: Are you taking oral contraception?
FEMALE CLIENTS ONLY: Are you pregnant or trying to become pregnant?
FEMALE CLIENTS ONLY: Are you lactating?
FEMALE CLIENTS ONLY: Are you currently having or due for your menstrual period?
MALE CLIENTS ONLY: Do you have any shaving challenges?
If yes, please explain.
Please select your beverage of choice, must be 21 years of age or older for alcoholic beverages, must have valid ID
PLEASE SUBMIT AND THEN CONTINUE TO THE WAIVER TO SIGN AND COMPLETE, THANK YOU.





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