FACIAL CONSULTATION FORM

Facial Consultation Form

Kindly Complete the Facial Consultation Form

Full Name*

Email Address*

Phone Number*

Date*

How did you hear about us? (Referral)

Speed mapping you started with La Ritz Spa and Salon's skin health system*

Have you ever used professional grade skin care products before Yes or No pls specify*

Your Skin*

Have you ever had a chemical peels, laser, microdermabrasion?*

Which of the following best describes your skin type?*

What areas of concerns do you have your:*

Eyes and Lips*

Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, or Retinol/Vitamin A products? Yes or No*

Have you used an acne medication? Yes Or No*

Have you experienced Botox, Restylane or Collagen Injections?*

Field label

Female Clients Only

Are you pregnant or trying to become pregnant? Yes or No*

Any menopause issues? Yes or No specify*

Are you undergoing hormone replacement surgery? Yes or No Specify*

Free Text

Male Client Only*

Do you experience irritation from shaving? Yes or No Ingrown hairs? Yes or No*

Sign Here:

Toll Free: (833) 953-1380
Mon-Sat: 10:00am-7:00pm, Sunday: Closed

Address: 905 Flat Shoals Rd SE, Conyers, Ga 30094