🌿 BloomBoom 30-Minute Facial Consultation Form

First name

Last name

Birthday

Month

Day

Year

Phone

Email

Address

Preferred Pronouns:

Yes, subscribe me to your newsletter.

Health History

Current Medications of Supplements (Including topicals):

Allergies (including latex, essential oils, nuts):

Skin Profile

Any recent peels, microdermabrasion, or laser treatments? (If yes, provide type & date)

Lifestyle Factors:

How would you rate your stress level?

Low

Moderate

High

Sleep quality:

Poor

Fair

Good

Excellent

Water intake:

<3 cups/day

3–6 cups/day

7+ cups/day

Diet:

Balanced

High sugar/ processed foods

Plant-based

Gluten-free

Smoker:

Yes

No

Social

Exercise frequency:

Rarely

Occasionally

Regularly

Treatment Goals:

Consent & Acknowledgement

I confirm the information above is accurate to the best of my knowledge.

I understand this facial is not a medical treatment and results may vary.

I agree to inform the esthetician of any discomfort or adverse reactions during the session.

I release BloomBoom and the esthetician from liability for any unintended outcomes due to undisclosed conditions.

Signature

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Date and time