Beauty Consultation Form

Name

First NameLast Name

Birthdate

Date

Email

example@example.com

Phone Number

Please enter a valid phone number.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What treatment are you interested in booking?

Have you had this type of treatment before?

YesNo

What do you consider your skin type?

Do you have any allergies I should know about? Please specify them all.

Do you have any injuries or medical conditions that might affect the treatment?

1) I give my permission to receive Chemical Peel, Eye Treatment Body Wrap and Scrub, Microdermabrasion 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 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 / 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

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.

7) I understand the importance of informing my therapist of all medicalconditions 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 session so he/she may adjust the treatment accordingly.

9) I understand that I or the therapist may terminate the session at anytime.

10)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.

11) I am aware that our appointments are subject to late cancellation due to guidlines in place with CV19 regulations.

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

Signature