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SKIN CONSULTATION FORM

First name*

Last name*

Phone*

Email*

Multi-line address

Country/Region*

Address*

City*

Zip / Postal code*

Birthday*

Year

Month

Day

MEDICAL HISTORY

Are you currently taking any medication prescribed by a GP or any other practitioner?*

Yes

No

If yes, please please provide further information:

Are you currently taking any medication containing vitamin A?*

Yes

No

If yes, please please provide further information:

Do you have any allergies? E.g. Aspirin, allergies to ingredients in products?*

Yes

No

If yes, please please provide further information

Are you attending any GP or other practitioner for any other conditions?*

Yes

No

If yes, please provide further information:

Skin Details - Please tick the appropriate box below:

Do you have any of these skin conditions?*

Dry (Tight, Dull & Flakey)

Combination (Dry Cheeks, Oily T-Zone)

Oily (Breakouts, Blackheads & Shiny)

Normal (Balanced & Smooth)

What are your main skin concerns?*

Fine Lines

Enlarged Pores

Acne

Scarring

Wrinkles

Pigmentation

Option 7

Redness/Rosacea

Uneven Skin Tone

Do you have a history of the following?*

Smoking

Sunbeds

None

How sensitive would you say your skin is?*

Mild

Very Sensitive

Moderate

Not Sensitive

Are you prone to or currently have the following?*

Eczema

Rosacea

Cold Sores

Psoriasis

None of the above

Do you get any of the following?*

Comedones/Blackheads

Cystic Acne

Hormonal Breakouts

Pustules/White Heads

Occasional Spots

Never Breakout

What are your skincare goals/what would you like to achieve?*

What is your current skincare routine?

Cleanse*

Toner*

Moisturizer*

Exfoliant*

SPF (if you use)*

Mask*

Eye Cream*

Please upload the following images of cleansed skin areas for one of our skin specialists to analyze your skin and your skincare recommendations.

Front (face only)*

Right Side (face only)*

Left Side (face only)*

I agree I have given the correct information above.*

I Agree

I give my permission for La Bella Med Spa to post any videos or photos of services performed on me and any relating descriptive information obtained on me to its social media sites including its website, Instagram and Facebook for educational purposes of the other clients.

I agree*

Yes

No

By using this form you agree with the storage and handling of your data by this website*

Yes

Signature*

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CONTACT
US

Tel. 365-661-4448

Email: labellamedspa0@gmail.com

3325 Mainway, Unit C

Burlington, L7M 1A6

VISIT
US

Monday - Friday 11:00am - 8:00pm

Saturday 11:00am - 4:00pm

Sunday - CLOSED

TELL

US

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