Consultation Form

New Client
Intake Form

Please fill out this form prior to your appointment date.

First name

Email

Last name

Date of Birth

Street Address

City

Apt/Unit

Zip

Your Health

Select All That Are True Required

Within the last year, I have been uder a dermatologist or other physician's care.

I smoke.

I exercise regularly.

I follow a restricted diet.

I wear contact lenses.

I have metal implants, a pacemaker, or body piercings.

I have had health problems in the past or present.

(If you have had health problems in the past or present, please specify.)

Rate your level of stress on a scale from 1-4. (1=low stress, 4= high stress)

List any medications, supplements, vitamins, diuretics, shimmering tablets, etc. that you take regularly.

Your Skin

Do you have any problems on your skin pertaining to your face or body?

Exfoliation History

If yes, how long ago?

If yes, when was it last used?

Are you using any products that contain any of the following ingredients? Select all that apply. Required

Nerve Activity

Have you ever had a reaction to any of the following?: Cosmetics, Medicine, Iodine, Pollen, Food, Hydroxy Acids, Animals, Fragrance, Sunscreen, Other. (If other, please specify.)

Female Clients Only

Male Clients Only

Questions to Discuss Every Visit

What are your skincare goals?

I confirm that the answers I have given are correct to the very best of my knowledge and that I have not withheld any information that may be relevant to my treatment.

I understand that the service offered is not a substitute for medical care. I also understand that any information provided by the therapist is for educational purposes only and not dignostically prescriptive nature.

I understand that the information herein is to aid the therapist in giving better service and is completely confidential.

I understand that The Sunny Method kindly takes cancelation requests up to 24 hours before the start of scheduled appointment. If canceled within 24 hours of your scheduled appointment, then 50% of your scheduled service will be requested before further services.

Your Signature

Select a date

We look forward to seeing you soon!

OTHER APPOINTMENT FORMS

Appointment Forms

Please print and fill out form specific to the service that

you will receive prior to your appointment.

Chemical Peel Form

Eyelash Extension Form

New Client Intake Form