Nature's Confidence Client Consultation Form

  • Client Consultation Form

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  • How did you hear about Nature's Confidence?*

  • Facial Client

    If you are not coming in for a facial, but are considering one in the future, please fill out questionnaire.
  • What are your skin care challenges?*
  • Have you ever had a facial or skin treatment before?*
  • What Skin Care Products do you currently use?
  • Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?
  • Have you received any of these hair removal services in the last 30 days?
  • Have you ever received chemical peels, laser services, or microdermabrasion treatments?
  • Have you received any Botox, Juvederm, or other dermal fillers in the last 2 weeks?

  • Teeth Whitening Client

    If you are not coming in for teeth whitening, but are considering one in the future, please fill out questionnaire.

  • Teeth Whitening Expectations

    • When whitening, you may feel a slight tingling.
    • Whitening product will not damage existing dental work.
    • Whitening product will remove stains from existing dental work, but will not whiten them beyond their original color.
    • White spots appear more prevalent directly after whitening, but the contrast will lessen within 24 hours.
    • Everyone's teeth respond differently and have their own natural "stop" point for whitening results.
    • Teeth may feel temporary sensitivity; sensitivity is typically minor and gone within 24 hours. You may choose to purchase a desensitizing treatment with your whitening. 
    • You may experience temporary gum irritation, which is more prevalent in clients that have brush abrasion from brushing teeth within 4 hours prior to whitening.


    To maintain healthy teeth and gums, it is recommended that you visit your dentist on a regular basis. If you have diabetes, heart conditions, pregnant, and/or currently breastfeeding you may consult with your doctor prior to using whitening products. Any existing mouth sores may feel temporary irritation during and/or after whitening.

  • If you have whitened your teeth within the last 6 months, you will have to schedule after the 6 months have past*

  • Bath Soak Client

    If you are not coming in for a bath soak, but are considering one in the future, please fill out questionnaire.

  • General Precautions Before Bathing

    Bathing waters can be contaminated by microorganisms (bacteria, parasites, viruses) or other pollutants. At Nature's Confidence, you can be rest assured that the proper disinfection and sanitation is being done after every service. We ask that you follow our precautions in order to prevent the spread of any contamination.

    • Before appointment, shower with soap and rinse well. That way you limit the amount of contaminants (sweat, secretions, skin particles, cosmetics residue, urine and feces) you can leave in the water
    • Go to the toilet just before bathing.
    • Do not swallow the water in which you are bathing
    • Avoid putting your head underwater in a spa in order to prevent infections.
  • I do not currently or have had any contagious skin infection, open wound, or a gastroenteritis bacteria within the last 2 weeks. Symptoms include, but not limited to: diarrhea, nausea, vomiting and fever.*

  • Your Health

  • I do not currently or have had in the past 2 weeks a contagious disease. This includes, but not limited to: Lice, Impetigo, Molluscum Contagiosum, Fungal Infections, Athlete's Foot, Scabies, Ringworm, Shingles, or any rashes and sores.*
  • Have you experienced any of these health conditions in the past or present?*
  • Do you?*
  • Do you take any of the following dietary / health supplements?*
  • Any known allergies?*
  • Have you used or been prescribed any medications (topical or oral) for acne / acne control?*
  • Are you a smoker?*
  • Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)*
  • Have you ever experienced claustrophobia?*
  • Please rate your stress level*

  • FEMALE CLIENTS

  • Are you taking birth control?*
  • Are you pregnant or trying to become pregnant?*
  • Any menopause issues?*
  • Are you undergoing any hormone replacement therapy?*

  • MALE CLIENTS

  • What is your current shaving system?*
  • Do you experience irritation from shaving?*

  • COVID-19 QUESTIONNAIRE

  • Have you or been in close contact with anyone who traveled within the last 14 days?*
  • Have you had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days?*
  • Have you experienced any cold or flu-like symptoms in the last 14 days (this includes, but not limited to: fever, cough, sore throat, respiratory illness, difficulty breathing)?*

  • If the answer is "Yes" to any of the questions, appointment will be denied.

  • COVID-19 PROTOCAL

    The following will be implemented upon arrival to your appointment

  • DO NOT BOOK APPOINTMENT IF YOU ARE EXPERIENCING OR HAVE EXPERIENCED ANY COLD/FLU SYMPTOMS IN THE PAST 2 WEEKS.

    (This includes, but not limited to: fever, cough, itchy throat, runny nose, etc.)

    • This Consultation Form must be completed 1 hour BEFORE appointment or your appointment will be rescheduled. (Required for new and returning clients). 
    • Face mask is required before entering building, and may be removed before service is performed.
    • Upon arrival, your temperature will be taken with a touchless thermometer. Your temperature must be below 99 degrees Fahrenheit or service will be denied.
    • You will be asked to remove shoes. If you are not comfortable removing your shoes, shoe covers will be provided.
    • All clients must wash their hands as soon as they enter the treatment room.
    • A UV Light Sanitizer is available to safely sanitize your phone, keys, & wallet. HIGHLY RECOMMEND.
    • Do not hesitate to ask any questions or express concerns before your service. Once service has started, please refrain from talking, unless necessary.

     

    As we ease into reopening, appointments will only be booked on Thursday-Saturday. 
    If these days do not work with your schedule, please email naturesconfidence@gmail.com 

  • Minors (all clients under the age of 18- unless otherwise emancipated) can only receive treatments with parental/legal guardian consent.

    For clients age 15 and under, the parent/guardian must always be present in the treatment room. For minors under the age of 18, a parent or guardian's signature is required below.

    I confirm that I have read and understand all information on the applicable forms for this treatment or service, and accept responsibility on my child’s behalf for any disclosures or liability described on those forms. I agree to supervise any home care procedures that are recommended as a result of the treatment.

     

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