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Client Appointment Request Form

First name(Required)

Last name(Required)

Phone(Required)

Is texting okay on this number?

Prefer texts only

Prefer texts calling okay

Prefer calls texting okay

Prefer calls only

Email(Required)

What type of session are you looking for?(Required)

Yoga

Skincare

Both

Unsure

First time to Goddess Aesthetics & Yoga?(Required)

Yes

Have you had a session before?(Required)

Yes (Skincare)

No (Skincare)

Yes (Yoga)

No (Yoga)

Looking for

Morning

Afternoon

Evening

Other

Wanting to book appointments on

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Wanting appointment

Within 1 week

Within 2 weeks

Within 3 weeks

Within 4 weeks

Longer than 1 month

Other

Last Skincare Service

Within 1 week

Within 2 weeks

Within 3 weeks

Within 4 weeks

Longer than 1 month

None

Last Peel Service

Within 1 week

Within 2 weeks

Within 3 weeks

Within 4 weeks

Longer than 1 month

None

Interested in

Refresher

Hydra

Dream

Luxe

I don't know

None

First Time Esthetics Clients

First name*

Last name*

Address*

Phone

Emergency Contact*

Phone

Your Occupation*

Birthday*

Month

Day

Year

Filled out Client Appointment Request Form?*

Yes

Referred to by*

Circadia

E-mail

Friend

Gift Certificate

Transcendence Massage & Yoga LLC

Other

What is the reason for your visit?*

What special areas of concern do you have?*

What condition(s) would you like to improve?*

Acne

Acne Scarring

Age Spots

Enlarged Pores

Fine Lines/Wrinkles

Hyperpigmentation

Stretch Marks

Surgical/facial scars

Other

Have you ever had facials before?*

Yes

If Yes Where?

What Was Your Experience?

How Would You Describe Your Skin?*

Do You?*

Do You Experience*

Flakiness

Redness

Tightness

Excessive oily shine during the day

Other

Have You Ever Had*

Peels

Microdermabrasion

Hydradermabrasion

Facial Surgery

Cosmetic Surgery

Botox

Collagen Injections

Laser Resurfacing

How Long?

What is your skin regimen?*

Soap & Water Only

Cleanser

Toner

Masque

Moisturizer

Exfoliation

Sunscreen

Other

Are You Ever Exposed to Chemicals, Oils, Cleaners, or Other Caustic Substances that May Aggravate Your Skin?*

Yes

If Yes What?

Do You Blush Easily?*

Yes

If Yes Why?*

Emotions

Foods

Temperature Changes

Other

Do You*

Sun Bathe

Use a Tanning Bed

How Often

Are You Under Treatment for any Current Skin Conditions?*

Yes

If Yes, What

How Does Your Skin Heal*

Fast

Scars

Pigmentation

Do You Bruise Easily*

Yes

Do You Get Sores/Blisters (Herpes Simplex/Zoster/Shingles)*

Yes

What Medications/Hormone Replacement/Vitamins Do You Presently Take?*

Have You Ever Used*

Accutane

Retin-A

Renova

Topical Antibiotics

Differin

Tazarac

Hydroquinone

Alpha Hydroxy Acids

None

If yes, when and for how long?*

Personal/Family History of Cancer*

Family

None

Do You Have any Allergies?*

Cardiac Conditions?*

Neurological Conditions?*

Are You Sensitive to Smells/Sensations?*

Smoke Tobacco?*

Yes

Do You Wear Contacts?*

Yes

List any contraceptives/replacement therapies/preferred body hair routine/other female medical conditions here *

Stress level*

Extremely Stressed

Stressed

Meh

I Don't Know What Stress Is

How's Your Sleep?*

Great

Could Be Better

Newborn at Home

What's Sleep?

Do You Regularly Excercise?*

Every day

4-6 days per week

3-5 days per week

1-2 days per week

Attempts are made inconsistently

Other

Water Intake Per Day*

Katerina may have a recommendation to alter/add to your home care regimen. Is this okay for her to recommend or are you good?*

recommend away

I'm open if it's worth the $$

not during service but in a text later

I'm good with what I have

Other

I _________________________________, do fully understand all the questions above and have answered them all correctly and honestly. I understand that the services offered are not a substitute for medical care. I understand that the skin care professional will completely inform me of what to expect in the course of treatment and will recommend adjustments to my regimen if deemed necessary. I also am aware that individual results are dependent upon my age, skin condition, and lifestyle. I agree to actively participate in following appointment schedules and home care procedures to the best of my ability, so that I may obtain maximum effectiveness.

In the event that I may have additional questions or concerns regarding my treatment or suggested home product routine, I will inform my skin care professional immediately. I release and hold harmless the skin care professional Kathryn Hannah, Goddess Aesthetics & Yoga, Eye of Illumination Inc., and the staff harmless from any liability for adverse reactions that may result from this treatment.

I have read and understood all of the foregoing information*

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