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Thalgo – Client Consultation Form
Cancellation Policy
APPOINTMENTS
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CONTACT
PRIVACY POLICY
CANCELLATION POLICY
Thalgo Facial
Client Consultation Form
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Name
*
Date of birth
*
Address
Phone number
*
Email
*
Referred by
Your Skin Care
Have you ever had a facial?
*
Yes
No
If yes, when?
Do you have any special skin problems or concerns pertaining to the face or body?
*
Yes
No
If yes, please specify
Do you use Retin-A, Renova, AHA or Retinol derivative products?
*
Yes
No
If yes, please specify
Have you used these products in the last 3 months?
*
Yes
No
If yes, when was the last time the product was used?
Have you ever had chemical peel, laser or microdermabrasion?
*
Yes
No
If yes, when?
Have you ever used an acne medication?
*
Yes
No
If yes, what medication and when?
What skin care products are you currently using? Name brands where possible.
*
Face Soap/Cleanser
Toner
Day Moisturiser
SPF
Exfoliator/Scrub
Mask
Eye Product
Night Moisturiser
Face Soap/Cleanser
Toner
Day Moisturiser
SPF
Exfoliator/Scrub
Mask
Eye Product
Night Moisturiser
What areas of concern do you have regarding your skin? (Please check all that apply)
*
Breakouts/Acne
Blackheads/Whiteheads
Excessive Oil/Shine
Submit
