Massage or Facial Consultation Form

Please complete the details below and return to Victorious Beauty prior to treatment, this form will then be stored.

Name *

First Name Last Name

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number *

Area Code Phone Number

Email *

example@example.com

How did you hear about Victorious Beauty ?

List any medications, supplements, or herbal remedies you currently take:

Please list allergies or sensitivities:

Please list Injuries or surgeries:

Have you ever received peressional treatments from a estetician?

Facial Relaxation massage Massage with cupping Hot Stone massage relaxation massage

Preferred Massage Pressure?

What are your specific concerns at this time regarding your skin? or what brings you in for a massage ?

What is your stress level right now?

Low Average Somewhat Stressed Very Stressed

What do you consider your skin type?

Normal Oily Acne Dry Aging Combination Sensitive Rosacea Other

What is your daily skin care regime?

Please check all that apply. *

What is your goal for this session.

By SUBMITTING THIS FORM, you agree to the following:

1) I give my permission to receive massage services.

2) I understand that therapeutic massage is not a substitute for traditional medical treatment or medications.

3) I understand that Victorious Beauty or my estetician does not diagnose illnesses or injuries, or prescribe medications.

4) I have clearance from my physician to receive massage therapy.

5) I understand the risks associated with massage therapy include, but are not limited to:

allergic reation
Superficial bruising or redness
Short-term muscle soreness
Exacerbation of undiscovered injury

I, therefore, release Victorious Beauty or my estetician from all liability concerning these injuries that may occur during the massage session.

6) I understand the importance of informing Victorious Beauty or my esteticianof all medical conditions and medications I am taking, and to let Victorious Beauty or my esteticianLouise's Nail & Beauty knowabout any changes to these. I understand that there may be additional risks based on my physical condition.

7) I understand that it is my responsibility to inform Victorious Beauty or my esteticianof any discomfort I may feel during the session so she may adjust
accordingly.

8) I understand that I or Victorious Beauty or my estetician may terminate the session at any time.

9) I have been given a chance to ask questions about the sessionand my questions have been answered.

Signature *

Clear

Date