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Please fill out the consultation form prior to your appointment if possible.

Consultation Form

If possible, please fill this form out before your appointment.

First name

Last name

Email

Phone

Date of Birth

Select an Address

Emergency Contact

Emergency Contact Number

How did you hear about Facial Garden?

What are you hoping to get out of todays facial?

I want to subscribe to the email list.

Medical and Cosmetic History

Do you have any allergies? *

No

Yes

List allergies here

Are you currently taking any medications? *

No

Yes

List medications here

Do you regularly have breakouts? *

No

Yes

If yes, how often?

Do you sunbathe or use tanning beds? *

No

Yes

If yes, how often?

Have you had collagen, botox, or other dermal filler injections? *

No

Yes

Does your skin burn easily in sunlight? *

No

Yes

Have you seen a dermatologist in the past year? *

No

Yes

If yes, please explain.

Do you use any prescription skin products, including Accutane or Retin-A? *

No

Yes

If yes, please specify?

Have you ever had a chemical peel, microdermabrasion, or laser treatment? *

No

Yes

If yes, what & when was your last treatment?:

Are you pregnant or nursing? *

No

Yes

Do you have any skin conditions? *

No

Yes

Do you have diabetes? *

No

Yes

Do you work outdoors? *

No

Yes

Do you have epilepsy? *

No

Yes

Do you wear contact lenses? *

No

Yes

Do you have a cardiovascular and/or thyroid condition? *

No

Yes

Do you have a history of smoking/tobacco use? *

No

Yes

Do you have trouble with wounds healing? *

No

Yes

Do you exercise regularly? *

No

Yes

Are you currently ill? *

No

Yes

Do you use SPF on your face? *

No

Yes

Have you ever been diagnosed with Cancer? *

No

Yes

If yes, are you undergoing Cancer treatment? *

No

Yes

Please list any other conditions, diseases, or disorders:

Please list any products you use on your face, including brand where able:

What is your skin type? *

Normal

Oily

Dry

Combination

Your skin is... *

Sensitive

Resilient

Not sure

Check any of the following words or conditions which describe your skin:

Thick

Loose

Wrinkled

Sun-damaged

Thin

Firm

Acne-prone

.

Freckled

Textured

Uneven

Cystic acne

Rosacea

Milia

Fine lines

.

Sallow

Psoriasis

Age Spots

Redness

Dehydrated

Large pores

By entering my full name below, I confirm that I have accurately completed the information above to the best of my knowledge. I agree to notify the provider of any other relevant information that may affect my procedure, including any changes to the information above. I release my provider of any and all liability of injury or damages that may arise because I have not represented my medical history accurately.

Full Name

Todays date

Thank you!

The Beauty and Wellness of your skin, comes from within

Lita Sergio

RN / Licensed Facial Specialist

ph: 352.630.3249

email: facialgarden@gmail.com

© 2023 Designed by Cassie Osborn

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203 North Third Street, Leesburg, FL 34748

*The Facial Garden uses Medical Grade PCA and other products for all of the facials.*

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