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Aroma Club & Spa
Aroma Club & Spa
Aroma Club & Spa
Spa Menu
Shop
Aromatherapy
Essential Oils
Forms
Client Consent Form
Client Consultation
Book A Consultation
Client Consultation
Aroma Club & Spa
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Client Consultation
Client Consultation
Step
1
of
3
33%
Name
*
First
Last
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Phone
*
Email
*
Does your job require the you work outdoors?
Yes
No
What would you like to achieve from your treatment today?
Have you ever had a facial treatment before?
*
Yes
No
When?
Which of the following describes your skin type?
*
Creamy Complexion: Always burns easily, never tans
Light Complexion: Always burns, tans slightly
Light/Matte Complexion: Burns moderately, tans gradually
Matte Complexion: Seldom burns, always tan well
Brown Complexion: Rarely burns, deep tan
Black Complexion: Never burns, deeply pigmented
Do you have any special skin problems or concerns pertaining to your face or body?
Yes
No
Specify:
Have you ever had any chemical peels, laser or microdermabrasion?
*
Yes
No
In the last month?
*
Yes
No
Do you use Retin-A-Renova, Adapalene Hydroxl Acid or Retinol/Vitamin A derivative products
*
Yes
No
Describe:
Have you used any of these products in the last 3 months?
*
Yes
No
Have you used an acne medication?
*
Yes
No
When?
Which drug?
What skin care products are you currently using?
Have you used any of the following hair removal methods in the past six weeks?
*
Shaving
Waxing
Electrolysis
Plucking
Tweezing
Stringing
Depilatories
None
Select all that apply.
Have you recently used any self-tanning lotion, creams or treatments?
Yes
No
Specify:
What areas of concern do you have regarding your skin: (Please check any that apply)
*
Breakouts/Acne
Blackheads/Whiteheads
Excessive Oil/Shine
Rosacea
Broken Capillaries
Redneck/Ruddiness
Sun Spot/Liver Spot/Brown Spot
Uneven Skin Tone
Sun Damage
Wrinkles/ Fine Lines
Dull/Dry Skin
Flakey Skin
Dehydrated
Other
Other
What areas of concern do you have regarding your eyes: (Please check any that apply)
Dehydrated
Wrinkles
Puffiness
Dark Circles
Other
Other
What areas of concern do you have regarding your lips: (Please check any that apply)
Dehydrated
Cracked/Chapped Lips
Other
Other
Have you ever had an allergic reaction to any of the following? (Please select any that apply)
*
Cosmetics
Medicine
Food
Animals
Sunscreens
Iodine
Pollen
AHAs
Fragrance
Shellfish
Latex
Drugs
None
Other
Other
What SPF do you use on your face?
What SPF do you use on your body?
Have you had any recent tanning bed or sun exposure that changed the color of your skin?
Yes
No
Specify:
Have you experienced Botox, Restylane or Collagen injection?
Yes
No
Specify:
Are you taking oral contraceptives?
*
Yes
No
Specify:
Any recent changes to or from your contraceptive treatment?
Yes
No
If so, what and when:
Are you pregnant or trying to become pregnant?
*
Yes
No
Are you lactating?
*
Yes
No
Any menopause problems?
Yes
No
Specify:
Are you undergoing any hormone replacement therapy?
Yes
No
Specify:
Future Appointments/Contact:
May I call you at your home, work or cell phone number to confirm future appointments?
*
Yes
No
May I contact you via mail/email about future promotions and news?
Yes
No
Signature
CAPTCHA
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Our Address
44832 Date Avenue
Lancaster, CA 93534
Call:
(661) 418-8291
Email:
info@myaromaclub.com
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