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Home
About
Services
Facials
Consultation Facial
Deep Pore Acne Facial
Customized Signature Facial
Firming Anti-Aging Facial
Bearded Man Facial
Gentleman's Facial
Signature Teen Facial
Cleopatra Facial
Mommy to Be Facial
Vitamin C Facial
Glow Getter Facial
Body Treatments
Backcial
Underarm Lux Facial
The Fanny Facial
Mechanical Exfoliation
Microdermabrasion
Micro-Peel Dermabrasion
Chemical Peels
Enzyme Facial
Progressive Peel
Mid-Depth Peel
Deep Peel
Post Peel Essential Facial
Enhancement Services
Skin Care Consultation
Virutal Skin Care Consultation
Bridal Consultation
Forms
Client Consultation Form
COVID-19 Treatment Consent
Shop
Book
Blog
eGift Card
Contact
Client Consultation Form
Your Health
Are you a New Client or Returning Client?
New Client
Returning Client
How did you hear about us?
Facebook
Instagram
Referral
Word of Mouth
Other
First Name
Last Name
Telephone
Cell Phone
1. Within the last year, have your been under a dermatologist’s or other physician’s care?
Yes
No
If yes, please specify
2. Have you had any health problems in the past or present?
Yes
No
If yes, please specify
3. List any medications, supplements, vitamins, diuretics, slimming pills, Isotretinoin, etc. That you take regularly
4. Do you smoke?
Yes
No
5. Do you exercise regularly?
Yes
No
6. Do you follow a restricted diet?
Yes
No
7. Do you wear contact lenses?
Yes
No
8. Do you have metal implants, a pacemaker or body piercings?
Yes
No
9. Rate your level of stress on a scale of 1 to 5 (1= Low stress, 5 = High stress)
1
2
3
4
5
10. Do you have any allergies?
Yes
No
If yes, please specify
11. Do you sunbathe or use tanning beds?
Yes
No
12. Do you drink more than 4 caffeinated beverages daily (coffee, tea, soft drinks)?
Yes
No
13. Have you ever experienced claustrophobia?
Yes
No
14. What are your specific concerns/challenges with your skin?
15. What skin care products are you currently using for your face?
Soap
Cleanser
Toner
Moisturizer
Masque
Exfoliator
Eye Products
15 B. What skin care products are you currently using for your body?
Soap
Shower Gel
Scrubs
Oil
Body Moisturizer
Depilatory Products
Self Tanners
16. Have you ever had chemical peels, Microdermabrasion, or any resurfacing treatments?
Yes
No
In the last month?
Yes
No
17. Do you use Retin-A, Renova, Adapalene or any other prescription skin products?
Yes
No
In the last 3 months?
Yes
No
18. Are you currently using any products that contain the following ingredients?
Glycolic Acid
Lactic Acid
Any exfoliating Scrubs
Any Hydroxy Acid Product
Vitamin A derivatives (i.e., Retinol)
19. Do you ever experience these conditions on your skin?
Flakiness
Tightness
Obvious Dryness
20. What SPF sunscreen do you use on your face?
20. What SPF sunscreen do you use on your body?
21. Do you burn easily in moderate sunlight?
Yes
No
22. Do you have a tendency to redness?
Yes
No
23. Do you suffer from sinus problems?
Yes
No
24. Do you ever experience burning, itching or stinging sensations on your skin?
Yes
No
25. Are you currently taking contraception?
Yes
No
26. Are you pregnant or trying to become pregnant?
Yes
No
27. Are you lactating?
Yes
No
28. Are you currently having or due for your menstrual period?
Yes
No
Thank you for contacting us.
We will get back to you as soon as possible.
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4303 S Bowen Road #127
Arlington, TX 76016
TextUs
817-614-0880
info@sereiaskinlounge.com
H
ours of Operation
M
onday - Closed
Tuesday - Friday 9am - 8pm
Saturday - 9am - 6pm
Sunday - 10am-5pm
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