Collagen Induction Therapy
sometimes you get lucky and find
a soul that grooves with yours.
sometimes you get lucky
and find a soul that
grooves with yours.
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( mm / dd )
First Name *
Last Name *
Date of Birth *
Which products do you currently use and how often? Include as much info as possible including brand.
Toner or Astringent
Sunscreen. If so, what SPF and how often?
Exfoliant (scrub, AHA gel or cream, enzymes, mask, etc.)
Topical Medications i.e. Retin-A, Differin, etc
How much time do you spend in the sun?
Do you use tanning beds? If so, how often?
Check one of the following: What happens to your skin if you are in the sun for 45-60 minutes at high noon with no sun protection?
Always burns, never tan
Usually burns, tans with difficulty
Sometimes burns, tan average
Rarely burns, tans easily
Very rarely burns, tans easily
Almost never burns, tans easily
What ethnicity are you?
Have you ever had skin cancer? If so, what type?
Are you allergic to any skin care ingredients, plants or medications?
I consider my skin to be sensitive
I have been diagnosed with rosacea
I consider my skin to be
Do you currently break out or have acne?
Have you had any plastic surgery, Botox or fillers? If so, when?
Have you ever had chemical peels, laser or microdermabrasion? If so, when?
I am diabetic
I have cold sores
I am HIV positive
I am a smoker
Do you have a pace maker or any other metal implants?
Any other medical conditions?
Please list any current medications
What if any supplements/vitamins do you take?
For Women Only:
I am currently on birth control
I am pregnant
If you are pregnant, when are you due?
I have regular periods
If not, how often?
I am going through perimenopause or menopause
I am post-menopausal
If so, how many years?
Please tell us how you would like to improve your skin. Be specific about what you would like to improve or what you expect from your treatments:
How did you hear about us?
Please Initial below each statement, indicating that you have read and understand the following:
I understand that Soulmate Skin's services including facials and body treatments are for the sole purpose of skin cleansing, improving the appearance of the skin, body and mind relaxation and rejuvenation. *
I understand that it is imperative to tell my Esthetician about any oral or topical medications prior to any facial, waxing, spray tanning or body treatment services. *
I understand that Soulmate Skin and staff do not diagnose illness, disease, or any other physical or mental disorder. I accept full responsibility of the use of Soulmate Skin at my own risk, and to not hold Soulmate Skin or staff liable for loss, damage or injury. *
I understand that results differ from client to client and are not guaranteed. I understand that compliance with home care recommendations can improve results. *
I confirm that to the best of my knowledge that the answers given on the client consultation form are correct and that I have not withheld any information that may be relevant to my treatment at Soulmate Skin. *
I authorize Soulmate Skin to perform superficial skin care treatments that are discussed with me . I understand that there are no guarantees and that the best results and outcomes are achieved by adhering to a proper homecare program and regular professional treatments as recommended by my Esthetician. I understand that Soulmate Skin is not a medical facility and employs no doctors or health care practitioners, only Licensed Estheticians.
I understand and acknowledge that Soulmate Skin has a 24 hour notice cancellation policy. It's my responsibility to keep the appointment or cancel with a minimum of 24 hours notice. I understand that I will be charged 100% of the full treatment price for any missed appointments or those not cancelled at least 24 hours before. I understand that if said appointment is prepaid, I will forfeit that appointment. *
May I email and/or text you to confirm future appointments?
May I email and/or text you about future promotions and news?
Collagen Induction Therapy