New Client Consultation Form

The Wellness Brand

This is your electronic consultation form
Please find the address for Treatments Wellness Studio at Pilsley

15 Barnetts Way
Pilsley
Chesterfield
S45 8BF

Here is the link
Link To Google Maps

You pull on estate take your first left and we are the house in the corner.
Please park on the drive where possible
Walk to the right hand side garage door and you will see a gate. The side door for the studio is just through the gate.

Please arrive on time for your appointment. If you are experiencing delays please let me know and I’ll do my best to accommodate
Today's Date*

DayMonthYear
Name*

First NameLast Name
Date of Birth*
Address

House Name/Number, Street Address Line 1

Street Address Line 2

Town/ City County

Postcode
Mobile Number *
07765559183
E-mail*
If Referral, please list name
Your Skin & Body

This is to understand your skin this will enable me to provide the best treatment outcome. PLEASE NOTE :All treatments include time for you to change and come around after your spa treatment. All treatments are subject to the completion of this online consultation form, adaptations will be made accordingly.
How did you hear about me?*

Website / Online SearchYelpFacebookReferralOther
What is your main reason for your visit? *
Which one of these statement describes you best, you can select more than one

Struggling to sleep, Insomnia, ExhaustionMind continuously racing, Unable to switch off, On edgeLethargic, No motivation, Water retention, Poor circulationJoint pain, Muscular pain, Back strain, Neck aches, Congestion, Feeling under the weather
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)
If you are seeking corrective treatments please detail the SPECIFIC products (BRAND & PRODUCT TYPE/NAME) you are currently using so I can best answer any questions on ingredients and help you meet your skin care goals.
Product details.
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 daysNoNot 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 / LaserDepliatory 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 two weeks?*

YesNo
Your Health & Wellbeing

This to understand your health and how we can continuously support your sense of wellbeing
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. If not mark N/A*
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 AcidMelatoninTuramericBiotinOther
If other, please list
Any known allergies?*

AspirinTree NutsLatexDairyFruitsVegetablesShellfishIodineFragrances / Essential OilsOtherNone
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
Please let me know if you would like to learn about natural ways to lower stress levels
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
Post Facial Care/Waxing Instructions: Aerobic exercise and/or vigorous physical activity should be avoided for 48 hours. Direct sunlight exposure is to be avoided immediately following the treatment (including any strong UV light exposure and/or tanning beds). If some sun exposure cannot be avoided first apply a broad spectrum sunscreen of SPF 30. Sunscreen (with a minimum SPF 15) should become part of your daily skin care regimen as skin can potentially become more sensitize to the sun as a result of this treatment. Unless otherwise specified, in the evening following your treatment, cleanse your skin with a mild cleanser and water followed by a non-active moisturizer. Do not apply additional exfoliating ingredients/products the day of your service as over-exfoliation can result in irritation or further sensitivity. Consult your skin care professional before resuming topical treatments. Enzyme peels, DermaFile or DermaDisc treatments, chemical peels or facial waxing can result in skin flushing/redness or slight skin flaking or sensitivity for up to 48-72 hours post treatment. DO NOT peel, pick, rub, or scratch your skin at any time, whatsoever. This can potentially cause damage or compromise your results.*

I have read the post care instructions and agree to adhere to them.
Cancellation Policy for all current and future appointments: In the event of cancellations received less than 24 hours prior to appointment, no Shows will be charged 100%*

I understand the cancellation policy at The Wellness Brand and consent to me being charged if I fail to give 24 hour notice for a cancelation or reschedule.
I hereby release and agree to hold The Wellness Brand harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the salon, or that may otherwise arise in any way in connection with any services received from The Wellness Brand . I understand that this release discharges The Wellness Brand from any liability or claim that I, my heirs, or any personal representatives may have against the salon with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from The Wellness Brand . This liability waiver and release extends to the salon together with all owners, partners, and employees.

I hereby relese
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 to the skin from treatments received. The treatments I receive here are voluntary and I release The Wellness Brand from liability and assume full responsibility thereof.

Yes
Signature*

Clear
What Happens Now ?

Once all of your party have filled out this form, your details and treatment choices will get entered into our appointment system.

You will get conformation of this though the comunication channels you have provided.

Please note we do not send out spam emails. If you decide to opt out we will be unable to contact you or confim your appointment though our sysem this makes comunication on the day a little challenging.

The only comunication you will receive from WB is a follow up email after your package with a review request and a £5 off voucher.

In all of of treatments we use our WB natural professional product range.

Take a nosey at our products and services before your pamper

Take a look on Instagram

Take a look on Facebook

Any question please give me a call on 07765559183. We look forward to taking you on your WB Journey with us soon.

Charlene,

Director of The Wellness Brand
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The Wellness Brand

Your Skin & Body

Your Health & Wellbeing