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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 > Client Consultation

Client Consultation

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Name*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code 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
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Our Address

44832 Date Avenue

Lancaster, CA 93534

Call: (661) 418-8291
Email: info@myaromaclub.com

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Aroma Club & Spa

44832 Date Avenue

Lancaster, CA 93534

(661) 418-8291
info@myaromaclub.com

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