Thank you for completing our consultation form. We look forward to welcoming you to Bliss Beauty for your treatment(s)Date*Date of Appointment*First Name*Surname*Age*Under 2020-3030-4040-5050-6060-70Over 70Email*Confirm Email*Address*Mobile Number*Please tick any of the following that applies to you (and give details below)Active Cold Sores/ShinglesAnxietyArthritisAsthma/Breathing DifficultiesAuto-Immune ConditionsBack PainBotox/Collagen/FillersBreastfeedingCancer (any form)ClaustrophobiaCosmetic Light-Based TreatmentsDiabetesEpilepsyFungal Infections (e.g. Athletes Foot)Headaches/MigraineHeart ConditionHigh/Low Blood PressureHighly Sensitive/Delicate SkinHIV/AidsHormone IrregularitiesHRT/Oral Contraceptive PillIBS and other Bowel ConditionsInflammation/Infection (in areas to be treated)Keloid ScarringKidney Related ProblemsMajor OperationsMetal Implant/Body PiercingsMultiple SclerosisMoles (in area to be treated)Muscle/Joint PainOver/Under-Active ThyroidPacemakerPregnancy (please give due date in box below)Prosthesis/Silicone ImplantRecent Fractures/SprainsRecent OperationsRosaceaSemi-Permanent Make-UpSevere/Active AcneSevere Muscle ConditionsSkin Conditions (Eczema/Psoriasis)Skin Lesions (in area to be treated)Swelling/OedemaRecent Sunbathing/Recent Use of Tanning BedsThrombosis/PhlebitisTumoursVaricose VeinsVerrucasTaking any type of blood thinners (excluding Aspirin alone)Taking Muscle RelaxantsTaking Anti-DepressantsUsing Isotretinoin/Taking Roaccutane (if you have stopped but have used/taken in the last 12 months please detail below)Please give pregnancy due date/use of tretinoin/Roaccutane and any further details with regards to the options you ticked above that may help your therapistAre you allergic or ever had any adverse reactions to cosmetics, foods, clothing, soap, shampoos, hair dye, perfumes or jewellery? (if yes please give details below)*YesNoDetails of allergiesAre you allergic to Aspirin?*YesNoPlease select which treatment(s) you will be receiving in Bliss Beauty at your consultation*Elemis Biotec FacialElemis Hands on FacialNeostrata Glycolic Peel (please note a patch test is required 24 hours before this treatment if you have not had it before)Frangipani Body ScrubMassageBliss Deep Cleansing Back TreatmentEar CandlingReflexologyManicure/PedicureCallus PeelTinting (please note a patch test is required 24 hours before this treatment if you have not had it before)Waxing (please note a patch test is required 24 hours before this treatment if you have not had it before)Spray TanEyelash ApplicationMake UpI understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.YesSignature Client If you are having a biotec/hands on facial/massage/reflexology please fill out the following section (otherwise skip to the next section)What are you average stress levels?Low (1-3)Moderate (4-6)High (7-10)Extreme (10+)How much water do you drink daily?None1-3 glasses4-6 glasses7-9 glasses10+ glassesHow many hours do you usually sleep?None1-3 hours4-6 hours7-9 hours10+ hoursDo you have a specific diet? (e.g. Vegan, Vegetarian, Keto, Paleo etc). If Yes please give details belowYesNoDetails of specific dietDo you have a healthy diet on the whole?YesNoDo you exercise regularly?YesNoDo you smoke?YesNoHow many cigarettes per day?Do you drink alcohol regularly?YesNoHow many units per week?How would you describe your energy levels?LowMediumHigh If you are having massage please fill out the following sectionMy body feelsFine-I just want to relaxTense and tiredSore/my movement is restrictedOther (please state below)Other concerns/informationIs there any particular area you would like your therapist to concentrate on during your massage? If so please give further details belowWhat is your pressure preference for your massageLightMediumFirm If you are having an Elemis Biotec/Hands on Facial or Neostrata peel please complete the sections belowWhat areas of concern do you have regarding your skin?AcneBlackheadsBroken CapilleriesCongestionDullnessDrynessDehydrationExcessive Oil/ShineFine Lines/WrinklesDeep Lines and WrinklesLoss of ElasticityMelasmaPigmentationPuffinessRosaceaRednessUneven Skin ToneWhiteheadsOther (please give details below)Details of other skin concernsWhat areas of concern do you have regarding your eye area?Fine Lines and WrinklesDeep Lines and WrinklesPuffinessDark CirclesDehydrationOther (please state below)Details of other eye area concernsDoes your job involve you working outside?YesNoDo you wear SPF on your face regularly?YesNoWhich of the following best describes your skin tone?I Pale White-always burns/never tansII White to Light Beige-tans minimally/burns easilyIII Beige-Burns moderately/ tans gradually to light brownIV Light Brown-burns minimally /tans well to moderately brownV Moderate Brown-rarely burns /tans profusely to dark brownVI Dark Brown or Black-never burns/ tans profuselyAre you currently using any of the following skincare?Cleanser/WashToner/SoftenerSerumsOilsDay CreamNight CreamEye CreamExfoliatorsMasksPeelsOther (please give details below)Details of other skincare productsWhat are your skin goals? What are you hoping to improve or maintain?Which skincare brand are you currently using? Teenage TreatmentsFirst Name of Parent/GuardianSurname of Parent/GuardianRelationship to Young PersonI _________________________________ am happy to give my consent for _______________________________ to have the specified treatment/s. I have checked the record card details and can confirm they are correct. Both myself and the young person fully understand what the treatment involves and have read and understood any pre-treatment and aftercare advice.YesSignature Parent/GuardianSignature Client Covid 19 PandemicI understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it and who does not, given the current limits in virus testing*YesI understand that due to the frequency of visits of other clients, the characteristics of the virus, and the characteristics of beauty services, that I have an elevated risk of contracting the virus simply by being in the salon.*YesI confirm that I am not suffering from any of the following symptoms. Temperature over 38 degrees celsius and/or shortness of breath and/or dry cough and/or loss of taste or smell*YesI confirm that I have not been around anyone with these symptoms in the past 14 days.*YesI do not live with anyone who is sick or quarantined.*YesTo prevent the spread of contagious viruses and to help protect each other, I understand that I will have to follow the salon’s guidelines.*YesI verify that I have not traveled outside the Ireland in the past 14 days to countries that have been affected by COVID-19.*YesSignature*Captcha Submit
