Beauty Consultation Form

Name

First NameLast Name

DOB

Date

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Number

Please enter a valid phone number.

Mobile Number

Please enter a valid phone number.

Occupation

Doctors Surgery

Doctors Name

Do you have any injuries or medical conditions?

If Yes, Please give details of your injuries or medical conditions.

Do you have any allergies?

If yes, please give details of allergies:

Have you had any surgeries in the last year?

If yes, please give details of surgeries:

Are you taking any Medication?

If yes please list the medication you are currently taking :

Are you Pregnant?

If yes how many weeks?

Are you breast feeding?

Are you using any resurfacing products containing retinol/AHA’s (e.g. glycolic acid)

Have you ever had a reaction to a previous beauty treatments or products

If yes, please give details:

Have you had COVID 19 vaccination?

Have you had COVID 19?

Please do no attend Beauty at the Lodge if you have COVID19 or suspect you may have it.

What treatments are you interested in?

What do you consider your skin type?

Patch Testing. If you have not had one of the following treatments within six months you must have a patch test prior to treatment.

EYE LASH/BROW TINTING, I have received a patch test for this treatment, prior to treatment and I am happy to go ahead understanding that reactions can still occur. I will not hold the therapist accountable for any reactions and will seek advice from a medical professional for assistance.LASH LIFTING, I have received a patch test for this treatment, prior to treatment and I am happy to go ahead understanding that reactions can still occur. I will not hold the therapist accountable for any reactions and will seek advice from a medical professional for assistance.BROW LAMINATION, I have received a patch test for this treatment, prior to treatment and I am happy to go ahead understanding that reactions can still occur. I will not hold the therapist accountable for any reactions and will seek advice from a medical professional for assistance.EYE LASH EXTENSIONS, I have received a patch test for this treatment, prior to treatment and I am happy to go ahead understanding that reactions can still occur. I will not hold the therapist accountable for any reactions and will seek advice from a medical professional for assistance.

When did you receive your patch test?

PLEASE NOTE:

Clients who are pregnant or breast feeding are unable to have the above treatments.

if you are under 16 years of age you are unable to have the above treatments. A parental form will need to be completed prior to treatment providing permission.

How did you hear about that us

1) I give my permission to receive Massage Treatments, Eye Treatment, Hand & Feet Treatments, Body Treatments, Facial Treatments or Waxing services.

2) Where an Eye Treatment has been completed I am fully aware that even with patch testing there is only a limited amount of exposure, and that a full treatment can still cause a reaction. I will contact my therapist if any irritation, side effect or unwanted issue arrives that is a direct cause of any eye treatment that is carried out and will seek medical advice, and I will not hold my therapist responsible.

3) I understand that therapeutic massage is not a substitute for traditional medicaltreatment or medications.

4) I understand that the therapist does not diagnose illnesses or injuries,or prescribe medications.

5) I have clearance from my doctor where necessary to receive the treatment I am booking for.

6) I fully understand and have been informed of the risks associated with massage, facials, and waxing include but are not limited to:

• Superficial bruising or redness

• Short-term muscle soreness

I, therefore, release Beauty at the Lodge and the individual therapist from all liability concerning these injuries that may occur during the treatment session as I am aware of the risks.

7) I understand the importance of informing my therapist of all medical conditions and medications I am taking, and to let the therapist know about any changes to these at any ongoing appointments. I understand that there may be additional risks based on my physical condition.

8) I understand that it is my responsibility to inform my therapist of any discomfort I may feel during the trestment so they may adjust the treatment accordingly.

9)Photos of your treatments may be taken to aid in record keeping, and to be used with your permission on social media to help advertise the services available.

10)I agree that my details will remain on file .

11) I have been given a chance to ask questions about the session and my questions have been answered.

12) For the safety of our clients, we maintain records of any health or medical conditions which may indicate that a particular service or treatment should not go ahead (eg allergies, pregnancy, skin conditions) or a particular product should not be used (eg products containing nuts, fish oils etc). These health records are not used for any other purpose. Client records are held securely within our salon software system and can only be seen by members of the salon team.I consent to you maintaining such records while I am a client.

Signature

Date:

Therapist Name:

Claire Barber

Therapist Treatment Notes: