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 (you'll get a little treat for your birthday month because we love celebrating you!)
*
-
Month
-
Day
Year
Date
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? If referred by a friend, select Other and enter their name so we may thank them.
*
Google / Internet search
Social media
Yelp
Referred by a friend (please enter their name below)
If referred by a friend, please provide their name, we would love to thank them!
Would you like to receive our newsletter?
*
Yes
No thanks
I'm already signed up, please keep 'em coming!
What brings you in today? Check all that apply.
I have skin care concerns and would like professional help in resolving them.
I want to relax and let go of stress, please focus more on where I hold tension - I know you'll give me glowing skin along with a hefty dose of calm. Thanks!
At the end of my service I would like to receive home-care recommendations based on my skin care concerns and goals.
Other
What are your main skin care concerns?
*
Do you have any special requests for or questions about your service?
Have you experienced microcurrent, LED light therapy, ultrasonic cleansing, high frequency or a chemical peel? If yes, what was your experience?
Lifestyle:
List any medical conditions you have (medical conditions and medications affect your skin and may limit specific modalities)
Are you taking any medications - oral and/or topical?
Have you had cosmetic surgery? If yes, please list.
Have you had any Botox or any other injectable within the last 14-days? NOTE: Services cannot be performed within 14-days of any injection. SOME TREATMENTS MAY CAUSE THE INJECTED SUBSTANCE TO MOVE EVEN OUTSIDE THE 14-DAY PERIOD.
*
Yes, and it has been more than 14-days from today
No
What is your stress level on a scale of 1-5? 1=pretty chill; 5=100% stressed out
*
Do you smoke?
*
No
Yes, nicotine only
Yes, marijuana only
Yes, nicotine & marijuana
Do you have any allergies? If yes, please list.
Anything else you wish to share? I love learning about my clients as it helps me provide superior customer service.
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:
Do you use any devices (i.e. Clairsonic brush, My Skin Buddy, etc)? Please list device name and frequency of use.
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 withing 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.
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