Body Treatment Questionnaire and Consent

Body Treatment Questionnaire and Consent

Client information and history that enables us to give you the best possible results in your care. Your information is confidential and is never shared with an outside source.
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email *
example@example.com
Phone Number *
Please enter a valid phone number.
Birthday *

Month Day Year
Date
Best way to contact you
Note: Appointment reminders are sent via email and text. If you're not already opted in, we will opt you in for text reminders with our platform, Schedulicity. You will receive a text alerting you to the opt-in.
How did you hear about us? *
Google search, Instagram, Facebook, etc, Yelp, if referred by a friend, please list their name
Would you like to be on our email list? You'll stay current on skin health, special VIP offers, and (when available) last-minute openings *

Yes No thanks I'm already signed up, please keep 'em coming!
What brings you in for a body treatment? *
Do you have any special requests for or questions about your service?
Lifestyle:
What is your stress level on a scale of 1 to 5? *
1 = pretty chill; 5 = completely stressed out
List any/all medical conditions you have
Some medical conditions make it unsafe to use certain modalities. To keep you safe, it is imperative you list all medical conditions even if you think they are not related to your skin.
List any medications (oral and topical), and/or any supplements you are currently taking
Do you smoke? *

No Yes, nicotine only Yes, marijuana only Yes, nicotine & marijuana
Do you have any allergies? If yes, please list.
Do you currently use, or have used in the last 6 months any Vitamin A products, prescribed or OTC, including but not limited to Retin A, Renova, AHAs, Retinol? Note, these products are in the blood stream and affect the skin on your entire body and not only at the site where applied. *

No Yes, currently Yes, in the last 6 months
Have you ever reacted to any products? *

Yes No
If yes, please describe:
Anything else you wish to share? I love learning about my clients as it helps me provide superior customer service.

Acknowledgements and Consent. *

	I agree / I understand
I understand that a body treatment may cause the skin to purge (breakout). This is a release of toxins and does not indicate a reaction to the service or the products. I will contact Skin Care by Alison immediately for assistance with the purge.
I understand that facial & body treatments given at Skin Care by Alison are for the sole purpose of skin cleansing, superficial treatment, and body & mind relaxation.
I understand that it is imperative to tell my esthetician about any oral or topical medications prior to any service, including but not limited to Retin A, Retinol, or any other Vitamin A derivative. I understand some medications may cause adverse reactions in my skin. Skin Care by Alison is not liable for any adverse reactions.
I understand that if I am applying Retin A anywhere on my body that it gets absorbed into my bloodstream and it doesn’t matter where it is applied, all my skin is affected.
I understand there are risks associated with skin care treatments; such as redness, sensitivity, peeling, purging (breakouts) or inflammation. I will discuss any concerns with my skin care therapist.
I understand that Skin Care by Alison & staff do not diagnose illness, disease or any other physical or mental disorder. I accept full responsibility of the use of Skin Care by Alison at my own risk, and do not hold Skin Care by Alison and staff liable for loss, damage or injury.
I understand that results are personable and not guaranteed.
I confirm that the answers given are correct and that I have not withheld any information that may be relevant to my treatment at Skin Care by Alison.
I certify I have not had any cosmetic injections, including but not limited to Botox, Dysport, Juvederm, & Restylane, within 14-days of my facial service. Services performed within 14-days will likely cause the product to move. Even outside of the 14-day period, I understand there is a risk of product movement and do not hold Skin Care by Alison responsible should the products remove,
I understand Skin Care by Alison has Cancellation & No-Show policies. I understand that I must provide at least 24-hours advance notice for the cancellation of an appointment. In the event of a late cancellation/no show the fee is the cost of the scheduled services. The credit card on file will be used to pay the fee. If a card is not on file (or declined), I understand an electronic invoice will be sent and I agree to pay within five (5) days of issuance. If Skin Care by Alison is able to replace the appointment with a client on our wait list, they are happy to waive the fee.
I accept full responsibility of the use of Skin Care by Alison at my own risk & do not hold Skin Care by Alison, Alison Phillips et al liable for loss, illness, damage or injury.

Signature

Clear
Best way to contact you. Note: Appointment reminders are sent via email and text.

Call me Email me Text me
How did you hear about us?

Google / Internet search Social media Yelp Referred by a friend (please enter their name below)
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Body Treatment Questionnaire and Consent

Lifestyle: