ConfidentialConsultationform

PersonalInformation

TodaysDate:_________________
Name:________________________________________________________________ Sex: Male Female
Last

First

M.I.

Address:_______________________________________________________ DateofBirth:______________
City:__________________________________________________State:________Zip:________________
PhoneNumbers:_______________________________________________________________
Home

Work

Mobile

EMail: ______________________________________________Occupation:___________________________
EmergencyContact:_______________________________________________ Phone:____________________
Whommaywethankforreferringyou?___________________________________________________________

Goalsforsession
Whatareyourlongtermskincaregoals?________________________________________________________________
Whatareyourareasofconcern?_______________________________________________________________________
Whatareyourgoalsforthistreatment?_________________________________________________________________

PersonalSkinCareHistory

Pleasecheck()currentproductsyouuse:
___Eyemakeupremover

___Skinfreshener(Toner,Astringent)
___Eyecream
___Facialscrub

___Bodylotion/cream

___Sunscreen#__________
___Cleansingcream/lotion

___Daycream

___Neckcream
___Exfoliants

___Bodyscrub

___Facialsoap
___Nightcream

___Mask

___Bodysoap
___Handcream

___Other:________________________________________________________

Haveyoueverhadafacialtreatment?_____Ifyes,whereandwhen?________________________________________
Wasitabeneficialexperience?________________________________________________________________________
Haveyoueverhadabody/busttreatment?______________________________________________________________
Howmuchtimedoyouspendonyourdailyskincare/makeuproutine________________________________________
Doyoutendtotanorburn?________________
Doyouexercise?Howmuch?____________________________
Doyousmoke?_______
Howmuchsleepdoyougetpernight?________________________________________
Howmuchdoyoudrinkofthefollowing:
None
Little
Moderate
Heavy

Water

___

___

___

___

Coffee

___

___

___

___

Tea(greenorblack)
___

___

___

___

Alcohol

___

___

___

___

SoftDrinks

___

___

___

___

Havetherebeenanyactivitiesorproductsthataggravateyourskin?________________________________________

HealthyLivingSpa611EastHawkinsParkway,Longview,TX75605,Spa(903)3236510*Fax(903)3236520www.GSMCInstitute.org

ConfidentialConsultationForm(pg2)
Clientsname:_______________________________________________

MedicalHistory

Last

First

M.I.

Pleasecheck()whereapplicablewithdetails.

___ Accutane

___ Distendedcapillaries

___ Pacemaker

___
___
___
___

Acne
Allergies
Arthritis___________________
Artificialimplants

___
___
___
___

Eczema
Epilepsy
Feverblisters
Heartcondition

___
___
___
___

Phlebitis
Plasticsurgery
Pregnant
Psoriasis

___
___
___
___
___
___
___
___
___

Asthma
Birthcontrol________________
Blooddisorder
Bloodthinner
Cancer
claustrophobia
Contactlens
Depression
Diabetic

___
___
___
___
___
___
___
___
___

Hepatitis
Highbloodpressure
HIV/AIDS
Hyper/Hypopigmentation
Hyper/Hypothyroid
Insomnia
Lupus
Metalplatesorpins
Naildisorders

___
___
___
___
___
___
___
___
___

RetinATM
Scleroderma
Seborrhea
Sensitivities
SkinCancer_______________
Surgeries
Underweight/Overweight
Vitamins_________________
Other____________________

Pleaselistmedication(s)includingvitamins,herbs&topicalsalves:_____________________________________________________
____________________________________________________________________________________________________________
Doyoutakeoruseanyproductsthatcontainthefollowing(circleallthatapply):
Isotretinoin
Tetracycline
RetinoicAcid
AHAGlycolicAcidHydroquinoneAspirinAnticoagulent
Haveyourecentlyhadanytypeofchemicalorglycolicpeel?__________

Ifglycolic,whatpercentage?_________________________________________________________________________

Ifchemical,Pleasedescribe:_________________________________________________________________________
Anyrecentsurgeryordermabrasion?_______Ifyes,Pleasedescribe:__________________________________________________
Anyallergies?______________________________ Areyoupregnant?_______Haveyoutannedinthelast24hours?___________
IsthereanythingelseIshouldbeawareofbeforeyourtreatment?_____________________________________________________
Haveyourecentlyundergonesurgery?(MedicalorCosmetic)__________________________________________________________

(pleasecheck()allthatapply)
FacialAnalysis
SkinType
__Normal__Dry__Combination__Oily__Sensitive/Breakout__Verysensitive/Rosacea__Acne__Mature
Whatareyourpresentskinconcerns?

___Acne Lesion (cysts) __Acne Scars __Dilated Capillaries __Papules (inflamed) __Pustules (inflamed) __Black Heads
__Whiteheads__IngrownHairs__Hyperpigmentation(Brownspotsfromsun,scars,hormonal)
__LackofElasticity
__DarkShadows
EyeArea
__CrowsFeet/Wrinkles __Puffiness

MouthArea
__Wrinkles
__Hyperpigmentation
__Nasolabialfolds

CheckArea
__Lossofelasticity__Crosswrinkling__SunDamage__Dilatedpores__UnevenTexture__VisibleCapillaries

Neck&DcolletArea__Wrinkles
__SevereSunDamage __LackofElasticity
__Hyperpigmentation

__Regularly
__Seldom
__Never
Howoftendoyoureceiveafacial?

HealthyLivingSpa611EastHawkinsParkway,Longview,TX75605,Spa(903)3236510*Fax(903)3236520www.GSMCInstitute.org

ConfidentialConsultationForm(pg3)
Clientsname:_______________________________________________
Last

InformedConsent&ReleaseForm
Facials,Waxing,Dermabrasion,&Peels

First

M.I.

PleaseReadandInitial:
_____ IhavecompletedtheConfidentialConsultationFormaccurately.Ihavebeencandidinrevealinganyconditions
that could prohibit treatments(s), such as cold sores, pregnancy, use of hormones, recent facial surgery or laser
resurfacing,recentuseofRetinATMoruseofAccutanewithinthelast18months.
_____ Iacknowledgethatthepossibilityofanadversereactiontoawaxing,facial,dermabrasionand/orpeelcanoccur
andthatthisisthecaseregardlessofprecautionstaken.IacceptsoleresponsibilityforthetreatmentsIreceiveandfor
anymedicalcarethatmaybecomenecessary.IwillimmediatelycontacttheEstheticianwhoperformedthetreatment
ofanyadversereactions.IntheeventthatIcannotreachsuchperson,Iwillimmediatelyseekmedicalcare.
_____ I fully understand that Healthy Living Spa and its agents may refuse to perform the treatments(s) I have
requestedifacontraindicationisstated.IunderstandthatIhavegivenupsubstantialrightsbysigningthisreleaseand
that it represents an agreement between me and Healthy Living Spa and me. I agree that my participation in
treatment(s)isvoluntaryandIaccepttheinherentrisks.
_____IherebyreleaseHealthyLivingSpa,itsagents,owners,employees,successorsandassigns,andsuppliersfromany
andalldamageorinjurythatmayresultfromthetreatmentIreceive.Irepresentthatalltheinformationprovidedby
me has been true and correct. I am over the age of 17 years old. I hereby authorize the therapist to perform said
treatment(s).
_____ The Esthetician has provided be the information necessary for me to have made the informed decision to
proceed with the treatment(s). He/she has answered all of my questions concerning the treatment(s). I clearly
understandtheaboveinformation.

__________________________________________________________________________________________
ClientsSignature

TodaysDate

__________________________________________________________________________________________
EstheticiansSignature

TodaysDate

HealthyLivingSpa611EastHawkinsParkway,Longview,TX75605,Spa(903)3236510*Fax(903)3236520www.GSMCInstitute.org