Simply Organic Skincare
Facial Consultation Form
Today’s Date_____________________________
Birthday ______/________/_______
Name____________________________________________________________________
Address___________________________________________________________________
City________________________________ State________ Zip____________________
Cell Phone (_____)_____________________ Email________________________________
How did you hear about us?__________________________________________________
What is your occupation?____________________________________________________
Have you ever had a facial?_____________
Do you currently get regular facials? _______________
If yes, how often?_______________________________________________________________________
Do you have any current medical conditions?
______________________________________________
If yes, please list:________________________________________________________________________
Are you taking any prescription medications, either topical or internal? ___________________________
If yes, what?
Topical___________________________ Internal_________________________________
Do you smoke? ______________
If yes, how much per day?________________________________
Do you get oily during the day? ___________________
If yes, what time of day? ____________
How much water do you drink daily? __________________
Caffeinated beverages daily?__________
How much alcohol do you drink weekly?
____1-3
____None
____4+
Allergies? Please list:_____________________________________________________________________
Do you consider your skin to be sensitive? ___________________________________________________
Describe your current skin care routine (please list brands):
Cleanser_________________ Toner_________________ Scrub_________________ Mask______________
Serum___________________ Moisturizer__________________ Sun block__________________
What are your goals for your skin?___________________________________________________________
_______________________________________________________________________________________