Nature's Confidence Client Consultation Form

Client Consultation Form
Name*

First NameLast Name
Date of Birth*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
How did you hear about Nature's Confidence?*

Website / Online SearchYelpInstagramTwitterFacebookReferralOther
If Referral, please list name
All referrals will receive 1 stamp. 10 stamps= A Free Express Facial
If Other, please let me know
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 goals?
What are your skin care challenges?*

Wrinkles / Fine LinesHyperpigmentation / Sun DamageAcne / Acne ScarringRedness / RosaceaAgingMelasmaSensitivityOther
Please feel free to go into more detail
Have you ever had a facial or skin treatment before?*

YesNo
If Yes, when?
What Skin Care Products do you currently use?

Cleanser / Face WashBar SoapFace Scrub / ExfoliantsTonerSerumsMoisturizerSunscreenEye Product(s)Lip Product(s)
Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?

Yes, currently usingYes, but not within the last 30 daysYes, but not within the last 6 monthsNoNot sure
Please specify which product or type, if you answered 'Yes, currently using' to above
Have you received any of these hair removal services in the last 30 days?

WaxingSugaringThreadingElectrolysis / LaserDepilatory CreamShavingNone
If checked, please note last time
Have you ever received chemical peels, laser services, or microdermabrasion treatments?

Yes within the last monthYes, within the last 2-3+ monthsNo
Have you received any Botox, Juvederm, or other dermal fillers in the last 2 weeks?

YesNo
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*

I have not whitened my teeth within the last 6 monthsI agree to not schedule until after the 6 months have past
Signature

Clear
By signing you acknowledge
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.

YesI agree to not schedule an appointment until 2 weeks AFTER I am fully recovered
Signature

Clear
By signing you understand and agree to adhere to the terms listed above
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.*

YesI agree to not schedule an appointment until 2 weeks AFTER I am fully recovered
Have you experienced any of these health conditions in the past or present?*

Hormone ImbalanceCancer / Systemic DiseaseHigh Blood PressureDiabetesHeart ProblemArthritisAuto-Immune DisordersAsthmaEpilepsy / Seizure DisorderFever BlistersHerpesFrequent Cold SoresHIV / AIDSLupusDepression / AnxietyHepatitisHeadaches / MigrainesOtherNone
If you checked yes to any of these please provide further information
Do you?*

Wear contact lensesHave a pacemakerHave metal implantsHave body piercingsNo, not applicable
Do you take any of the following dietary / health supplements?*

MultivitaminVitamin CVitamin D / D3ZincOmega 3 / Fish OilB Complex / B12GarlicCalciumFolic AcidMelatoninCoenzyme Q10BiotinOther
If Other, please list
Any known allergies?*

AspirinTree NutsLatexDairyFruitsVegetablesShellfishIodineFragrances / Essential OilsHydrogen PeroxideOtherNone
If Other, please specify
Have you used or been prescribed any medications (topical or oral) for acne / acne control?*

YesNo
If Yes, please specify what and date last used
Are you a smoker?*

YesNoSocial
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)*

YesNo
Have you ever experienced claustrophobia?*

YesNo
Please rate your stress level*

LowMediumHigh
FEMALE CLIENTS
Are you taking birth control?*

YesNoN/A
If Yes, what kind?
Are you pregnant or trying to become pregnant?*

YesNoRecently had a baby and am breastfeedingN/A
Any menopause issues?*

YesNoN/A
If Yes, please specify
Are you undergoing any hormone replacement therapy?

YesNo
If Yes, please specify
MALE CLIENTS
What is your current shaving system?*

Razor / Wet ShaveElectricN/A
Do you experience irritation from shaving?*

YesNoN/A
COVID-19 QUESTIONNAIRE
Have you or been in close contact with anyone who traveled within the last 14 days?*

YesNo
Have you had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days?*

YesNo
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)?*

YesNo
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
I have read the protocol and agree to adhere to all the terms listed above. I understand that by refusing will result in denial of any service.*

Yes
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation from treatments received. The treatments I receive here are voluntary and I release this skin care professional from liability and assume full responsibility thereof.*

Yes
Signature*

Clear
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.
Signature

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What music would you prefer to be listening to during your service? (:
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Client Consultation Form

Facial Client

Teeth Whitening Client

Bath Soak Client

Your Health

COVID-19 QUESTIONNAIRE

COVID-19 PROTOCAL