Aesthetics Consultation Intake

Experience a more personalized approach to aesthetic care. Your consultation is designed to help your provider understand your concerns, priorities, treatment history, and desired outcome. During your visit, your provider will assess your skin and facial or body anatomy, review your current skincare routine, and discuss appropriate treatment options based on your goals, medical history, timeline, and comfort level.

Please bring the skincare products you currently use. Your provider will consider what is already working for you and recommend only the changes that may add value as part of a customized aesthetic plan.

A $75 consultation fee is collected as part of this comprehensive evaluation. The full fee will be applied toward any aesthetic service, skincare purchase, or package purchased on the same day as your consultation.

First Name

Last Name

Phone

Date of Birth

Preferred Pharmacy Name

Pharmacy Address

Pharmacy Phone

Date of Last Eye Exam

Are you currently pregnant, breastfeeding, trying to become pregnant, or planning a pregnancy?

Yes
No
Not applicable

Do you currently have an active rash, infection, open wound, cold sore, dental infection, or inflamed acne in an area you may want treated?

Yes
No
Not applicable

Have you ever had severe allergies, anaphylaxis, or an allergy or reaction to lidocaine, local anesthetic, latex, adhesives, injectable products, or skincare products?

Yes
No
Not applicable

Do you have a bleeding disorder, easy or unexplained bleeding, or a history of blood clots?

Yes
No
Not applicable

Have you been diagnosed with an autoimmune condition, immune deficiency, poor wound healing, keloid or hypertrophic scarring, or a condition requiring immunosuppressive treatment?

Yes
No
Not applicable

Have you had skin cancer, radiation to the proposed treatment area, or a changing, bleeding, or non-healing skin lesion that has not been evaluated?

Yes
No
Not applicable

Have you ever developed prolonged pigment change, scarring, infection, burns, fat loss, nodules, vascular occlusion, vision symptoms, or another significant complication after an aesthetic treatment?

Yes
No
Not applicable

Have you been diagnosed with a neuromuscular disorder, difficulty swallowing, or significant breathing weakness?

Yes
No
Not applicable

Have you had a history of melasma or darkening or lightening of the skin after irritation, injury, or a procedure?

Yes
No
Not applicable

What would you like to discuss today?

Please check all that apply

Facial balancing, volume, or injectable treatment
Lines or expression wrinkles
Skin quality, tone, pigment, redness, texture, or acne scarring
Skin tightening or laxity
Body contouring or localized fat reduction
Hair thinning or hair-restoration options
Professional skincare or a home-care plan
I am not sure and would like guidance

What matters most to you when considering treatment?

Please check all that apply

Natural-looking results
Minimal downtime
Fastest appropriate improvement
A budget-conscious plan
A gradual, step-by-step plan
Long-term skin health and prevention

Which concerns would you most like to address?

Please check all that apply

Fine lines or expression wrinkles
Facial volume loss or contour
Facial volume loss or contour
Skin laxity
Uneven texture, pores, acne, or scarring
Pigment, redness, or uneven tone
Body contour or localized fat
Hair thinning
Other

If other, please describe:

Please describe the area that concerns you most and what you hope will look or feel different.

Do you have an upcoming event or deadline for treatment results?

If yes, please request appointment date:

Please bring the skincare products you currently use to your consultation. We will consider what is already working for you and recommend only targeted additions, substitutions, or adjustments that may improve your routine.

Do you have a history of skin sensitivity or reactions to skincare?

If yes, please explain:

Have you had prior injectable or aesthetic treatments?

If yes, please list the treatment or product, area treated, approximate date, and whether you were satisfied with the outcome.

Have you had prior cosmetic or facial surgery?

If yes, please list the procedure, approximate date, and any complications or revisions.

Have you ever had an adverse or unexpected outcome from an aesthetic treatment?

If yes, please describe the treatment, what occurred, whether medical treatment was required, and whether the issue fully resolved.

Have you ever had a cold sore, fever blister, or herpes outbreak on or near the area you may want treated?

If yes, when was your last outbreak?

Do you use antiviral medication?

Are you currently taking or using any of the following?

Check all that apply

Prescription blood thinner or daily aspirin
Frequent ibuprofen, naproxen, or another anti-inflammatory medication
Oral isotretinoin / Accutane
Antibiotic for an active infection
Systemic steroid or immune-suppressing medication
Medication for a neuromuscular condition
Prescription medication applied to the proposed treatment area
None of the above

Other medication the provider should know about:

Please list any allergies you have:

Please list all past medical/health issues:

I understand that this intake supports my aesthetic consultation and medical evaluation. Completing this form or paying the consultation fee does not guarantee that I am a candidate for, or will receive, any procedure, product, prescription, or treatment.

I certify that the information I provided is complete and accurate. I agree to disclose relevant medical conditions, allergies, medications, previous procedures, and complications that may affect my care.

I understand that my provider will use my goals, medical history, examination findings, risk factors, expected benefits, and clinical judgment when making recommendations. My provider may delay or decline treatment, request additional information, or recommend evaluation by another clinician.

Aesthetic results vary, and no specific result, duration of effect, or complication-free outcome can be guaranteed. This acknowledgment applies only to the consultation and evaluation. Before treatment, I will have an opportunity to review the recommended procedure, benefits, alternatives, risks, limitations, aftercare, and warning signs, and I may be asked to sign a separate treatment-specific consent.

A $75 consultation fee is collected for my personalized aesthetic evaluation. If I purchase an aesthetic service, skincare product, or treatment package during the consultation, the full fee will be applied to that same-day purchase. Payment does not guarantee that a procedure will be recommended or performed.

I understand that cancellations, rescheduling, missed appointments, no-shows, consultation fees, and refunds are governed by Feel Ideal 360’s current policies.

By signing below, I confirm that I have read and understand this acknowledgment and voluntarily consent to the consultation and evaluation described above.

Signature

I understand that this form is used to help direct my consultation and does not guarantee that I am a candidate for any specific treatment. I understand that treatment recommendations, if appropriate, will be based on my history, goals, exam, medical evaluation, risks, contraindications, and provider judgment.

Date

Billing Address

Address Line 1

Address Line 2

City

Country

Select

State/Province

Select

Zip Code

Sub Total

$75.00

TOTAL

$75.00

Payment Method

Credit Card - Square

* By clicking “Send,” you consent to receive calls, emails, and text messages from Feel Ideal 360 at the phone number and email you provided, including via automated technology. Consent is not a condition of purchase. Message and data rates may apply.

Thank you for contacting us!

Thank you for taking the first step toward a more personalized approach to aesthetic care at Feel Ideal 360!

We’ve received your information, and our team will review your concerns, goals, and current skincare routine so we can better prepare for your consultation.

During your visit, we’ll take the time to understand what is working for you, what may need to change, and which treatment options are best suited to your needs. Please remember to bring the skincare products you currently use so we can provide more personalized recommendations and begin creating a customized plan for you.

We look forward to speaking with you!

Dr. Straface and the

Feel Ideal 360 team

View Submission