About this template
A Microdermabrasion Consultation Form is essential for estheticians, medical spas, and skin clinics to screen clients safely before administering treatments. This form gathers crucial client data, including general contact details, comprehensive medical history, current medications, recent dermal treatments, and specific skin conditions that may impact procedure safety.
Using Doc2Form, you can instantly turn this structured layout into a live Google Form. By capturing allergy disclosures, pregnancy status, and treatment consent beforehand, practitioners can customize sessions to each client's skin profile while maintaining professional safety standards. It streamlines the intake workflow, eliminates paper clutter, and ensures both the clinic and the client are fully aligned before starting any aesthetic procedure.
Key features
- Screen clients safely for skin sensitivities and medical contraindications.
- Collect detailed history on recent chemical peels, lasers, and medications.
- Streamline client intake digitally before they arrive at the clinic.
- Ensure complete transparency with built-in consent and terms acceptance.
Use cases
- Pre-treatment screening at medical spas and boutique skin clinics.
- Initial client intake for independent licensed estheticians.
- Dermatology clinic aesthetic procedure documentation.
What this form collects
- Full Name (Short answer)Enter your first and last name as it appears on official documents.
- Date of Birth (Date)Please provide your date of birth.
- Phone Number (Short answer)Enter the best phone number to reach you regarding appointment updates.
- Email Address (Short answer)We will send your pre- and post-care instructions here.
- Home Address (Paragraph)Enter your current residential address.
- Current Medications, Supplements, or Substances (Multiple choice)Are you currently taking any prescription medications (e.g., Accutane, Retin-A), blood thinners, or regular supplements?
- Medication Details (Paragraph)If you answered yes above, please list the specific medications or substances and when you last used them.
- Recent Dermal Treatments (Multiple choice)Have you had any chemical peels, laser treatments, waxing, or facial fillers in the past 4 weeks?
- Recent Treatment Details (Paragraph)Please describe the recent treatments and exact dates if applicable.
- Pregnancy or Lactation Status (Multiple choice)Are you currently pregnant, trying to conceive, or breastfeeding?
- Known Allergies (Multiple choice)Do you have any allergies to latex, topical numbing agents, specific skincare ingredients, or metals?
- Allergy Details (Paragraph)Please list any known allergies and your typical reaction.
- Past Medical History (Multiple choice)Do you have a history of abnormal scarring (keloids), cold sores/herpes simplex, eczema, rosacea, or bleeding disorders?
- Medical History Details (Paragraph)Please provide details on any relevant medical conditions checked above.
- Additional Notes or Skin Concerns (Paragraph)Is there anything else your esthetician should know about your skin goals or sensitivities?
- Terms and Consent Acceptance (Multiple choice)I confirm that the information provided above is accurate to the best of my knowledge. I understand the risks associated with skin exfoliation treatments and consent to receive microdermabrasion.
- Digital Signature (Type Full Name) (Short answer)Typing your full name here serves as your electronic signature confirming consent.
- Signing Date (Date)Select today's date.
FAQ
Why is a microdermabrasion consultation form necessary?
It identifies potential contraindications such as active acne, rosacea, recent sun exposure, or specific medications that could cause adverse reactions to exfoliation treatments.
Can I customize the questions in this Google Form template?
Yes. Once generated in Google Forms, you can freely edit, add, or remove any questions to fit your specific clinic policies and treatment offerings.
How do clients sign the consent section?
The form includes a text acknowledgement field where clients can type their full legal name and date to confirm agreement with the clinic's treatment terms.
Is this form mobile-friendly for clients?
Yes, Google Forms automatically adapts to smartphones, tablets, and desktop computers, making it easy for clients to fill out prior to their appointment.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.