Coronavirus

1

We're excited to see you for your appointment at ÉCLAT Skin Confidence Spa! We require a check-in online for all spa appointments. This helps to confirm our time with you, gather information about changes to your health and ensure all consents for your visit have been completed.

2

Name* This field is required.

3

In the past 2 weeks have you had Covid OR received a vaccine / booster?(If yes, microneedling, PMU and peels may not be performed due to slower healing)

YES

NO

4

Have you received a COVID vaccine in the last 2 weeks? (Vaccines are not required)* This field is required.

Yes

No

5

If "yes" please explain (write N/A for NO)

6

Did you receive a vaccine in the last 7 days? (write N/A for NO). Please text us at 704.890.1071 to discuss your treatment if you've been recently vaccinated. * This field is required.

7

Are you experiencing COVID symptoms (cough, shortness of breath, fever, chills, body aches)?* This field is required.

YES

NO

8

Are you currently taking antibiotics, blood thinners, steroids or GLP-1's? Are there ANY change in your health or medications since your last visit?* This field is required.

YES

NO

9

If "yes" please explain:

10

Have you received Botox in the last (10) days, Filler or Laser Treatments in the last (28) days?* This field is required.

YES

NO

11

If "yes" please explain:

12

Have you had any alcohol or caffeine within the last 48 hours?* This field is required.(Alcohol and caffeine should be avoided 24-48 hours before any microneedling or PMU service to avoid excessive bleeding, redness and prolonged healing.)

YES

NO

13

What are your goals for this visit? * This field is required.Please provide any areas of concern or focus

14

Would you like your esthetician to choose a treatment for your concerns or are you happy with the service you booked?* This field is required.

YES, I want my esthetician to choose

NO, I am happy with the treatment I booked

15

NEW CLIENTS: Skin History & Consent is required before your first service. EXISTING CLIENTS: Treatment consents must be updated annually. Please confirm which forms are being submitted for your appointment:* This field is required.

N/A My forms are up to date.

Lash / Brow Consent

Microneedling Consent

CryoSculpting Consent

Skin History & Consent

Permanent Make-Up Consent

16

PLEASE READ AND CHECK EACH BOX TO CONFIRM YOU UNDERSTAND AND AGREE* This field is required.

If my health changes, I will notify the spa immediately.

If my medications change, I will notify the spa immediately.

I understand masks are OPTIONAL, but recommended if I am uncomfortable being around others who may be unvaccinated or unmasked.

17

I CONFIRM I HAVE ANSWERED ALL QUESTIONS AND STATEMENTS WITH HONESTY. * This field is required.

18

Enhancements are available to elevate your experience. Are you interested in adding any of the following treatments to your facial?* This field is required.

Dermaplane ($30)

Brow Wax ($15)

Chest Facial ($25)

Collagen Gloves ($15)

Extractions ($15)

Peppermint Scalp Massage ($15)

Foot Scrub & Massage ($30)

DMK Medi-Pedi Foot Treatment ($50)

None, thank you !

19

Has your service been prepaid?* This field is required.Please confirm below and present your eGift card, voucher or gift certificates to your esthetician:

Paper Gift Certificate

ECLAT eGift Card

Groupon Voucher

Prepaid / Package

N/A

20

Do you need a Silent Appointment? * This field is required.A silent appointment is little to no talking between you and the esthetician. Please don’t hesitate to ask for a silent appointment if you’re anxious, tired, or mentally drained and want to avoid conversation and have quiet time. There will be no judgments! Just let us know if you need to utilize this option .

YES, please NO, thank you

21

CUSTOMER SIGNATURE:* This field is required.PLEASE SIGN AND CLICK THE SUBMIT BUTTON BELOW

Clear