American Apothecary Holistic Skincare Coaching Discovery Form

(Start here to begin your healthy skin journey!)
Date *

Name (first and last) *

Address *

City, State, Zip Code *

Phone Number *


What is your biggest skincare concern?

Are you under a Physician's care or have any medical issues past or present? *

Do you experience hormonal symptoms during the month?

Describe your symptoms (ex hormonal breakouts, where and when do they occur?)

Do you experience digestive symptoms like IBS or Constipation?

Are you taking prescription medications (this includes skincare, birth control, creams, or ointments)? *

List your prescriptions *

List any supplements you are taking *

Do you have any allergies? *

Give an example of your typical meals in a day? (Breakfast, Lunch, Dinner Snacks) *

How many glasses of water do you drink a day? *

What fats do you eat/ cook with? *

When do you finish watching tv/ working on the computer at night? *

How many cups of coffee do you drink a day and when is your last cup? *

Rate your stress on a daily basis *

List your skincare products and routine
(cleanser, toner, exfoliant, serum, moisturizers and masks as well as tools) *

List your body care items. (deodorant, body wash, body scrub, body moisturizer, perfume) *

I have read the above information. If I have any concerns, I will address these with my skin care therapist. I give permission to my therapist to perform the tinting procedure we have discussed, and will hold him/her and his/her staff harmless from any liability that may result from this treatment. I have accurately answered the questions above, including all known allergies, prescription drugs, or products I am currently ingesting or using topically. I understand my esthetician will take every precaution to minimize or eliminate negative reactions as much as possible. In the event I may have additional questions or concerns regarding my treatment, I will consult the esthetician immediately. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand, the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the esthetician, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today. *

Appointment Policies:
A 24 hour notice of appointment cancellation is greatly appreciated. Last minute cancellations and no-shows will be subject to the full cost of the missed appointment. This allows other guests to fill the appointment and allows us to continue to provide excellent service and accommodations.

Please arrive a few minute prior to your appointment so that you get the full treatment time. If you are going to be more than 10 minutes late your treatment time will be changed to fit the time remaining, however, the scheduled service fee will remain the same.

At 10 minutes late we will need to reschedule your appointment. The service fee will be due as it is considered a no-show.

In the event that you don't arrive for your appointment or cancel less than 24 hours you will be invoiced via email for the cost of the service(s) scheduled

Product Returns.Product returns are accepted 7 days unopened or in the case of a true medical allergic reaction(breakouts are not considered an allergic reaction). Please take a photo of any issues and report to American Apothecary Skin within 24 hours of reaction. No exceptions.

Gift Certificates
There are no refunds issued on services rendered or gift certificates.
These policies are subject to change without notice.

American Apothecary Skin reserves the right to refuse service to anyone. *

I can't wait to for you to get started on achieving healthy skin! I look forward to meeting and talking with you soon!



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