Name*

First Name Last Name

Address*

Address

Address line 2

Town County

Post Code

Email*

example@example.com

Home Number

Area Code Phone Number

Mobile Number*

Area Code Phone Number

What treatments are you looking for?*

Eyelash Extensions Nail Treatments Facial Treatments Waxing Treatments

Date of preferred appt date (if known)

Date

Please sign to confirm your agreement to adhere to the guidlines

Clear

Please sign to confirm your agreement to adhere to the guidlines

Clear

Please check all that currently apply.*

Please list any other current health conditions not mentioned above

Please list any medications, supplements, or herbal remedies you currently take:

Would you know if your conditions require a doctor to agree with your required treatment?

Please give a full list of allergies or sensitivities:

At time of completing this form what is your health status?

Full Name of your registered & Surgery*

Doctor's Address*

Surgery Address

Address Line 2

Town County

Postal Code

What do you consider your skin type?

What is your daily skin care regimen? (only applicable for facial treatments)

What is your stress level right now?

Low Average Somewhat Stressed Very Stressed

By SUBMITTING THIS FORM, you agree to the following:
1) I give my permission to receive Eye Lash Enhancements, Massage, Facials, Nail 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 may have a different outcome, 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.
3) I understand that therapeutic massage is not a substitute for traditional medical
treatment 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 / therapy I am booking for.
6) I fully understand the risks associated with massage therapy, facials, and waxing include, but are not limited to:
• Superficial bruising or redness
• Short-term muscle soreness
• Exacerbation of undiscovered injur

I, therefore, release R3balance beauty and the individual therapist from all liability concerning these injuries that may occur during the treatment session as I am aware of the risks.
6) 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.
7) I understand that it is my responsibility to inform my therapist of any
discomfort I may feel during the session so he/she may adjust the treatment
accordingly.
8) I understand that I or the therapist may terminate the session at any
time.

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 am aware that our appointments are subject to late cancellation due to guidlines in place with CV19 regulations.
11) I have been given a chance to ask questions about the session
and my questions have been answered.

Signature*

Clear

Correct PPE is to be worn by both parties (this is still to be finalised in government guidelines), contact will be made prior to arrival - and if the client requires PPE and has not brought their own, a small additional charge will be added to your bill.

HEALTH RECORD

Terms and Conditions