Opening Hours

Monday	9.30am – 6.00pm
Tuesday	9.30am – 6.00pm
Wednesday	9.30am – 6.00pm
Thursday	9.30am – 9.00pm
Friday	9.30am – 8.00pm
Saturday	9.30am – 6.00pm

Click to open/close Consultation Form

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 20

20-30

30-40

40-50

50-60

60-70

Over 70

Email*

Confirm Email*

Address*

Mobile Number*

Please tick any of the following that applies to you (and give details below)

Active Cold Sores/Shingles

Anxiety

Arthritis

Asthma/Breathing Difficulties

Auto-Immune Conditions

Back Pain

Botox/Collagen/Fillers

Breastfeeding

Cancer (any form)

Claustrophobia

Cosmetic Light-Based Treatments

Diabetes

Epilepsy

Fungal Infections (e.g. Athletes Foot)

Headaches/Migraine

Heart Condition

High/Low Blood Pressure

Highly Sensitive/Delicate Skin

HIV/Aids

Hormone Irregularities

HRT/Oral Contraceptive Pill

IBS and other Bowel Conditions

Inflammation/Infection (in areas to be treated)

Keloid Scarring

Kidney Related Problems

Major Operations

Metal Implant/Body Piercings

Multiple Sclerosis

Moles (in area to be treated)

Muscle/Joint Pain

Over/Under-Active Thyroid

Pacemaker

Pregnancy (please give due date in box below)

Prosthesis/Silicone Implant

Recent Fractures/Sprains

Recent Operations

Rosacea

Semi-Permanent Make-Up

Severe/Active Acne

Severe Muscle Conditions

Skin Conditions (Eczema/Psoriasis)

Skin Lesions (in area to be treated)

Swelling/Oedema

Recent Sunbathing/Recent Use of Tanning Beds

Thrombosis/Phlebitis

Tumours

Varicose Veins

Verrucas

Taking any type of blood thinners (excluding Aspirin alone)

Taking Muscle Relaxants

Taking Anti-Depressants

Using 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 therapist

Are 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)*

Yes

Details of allergies

Are you allergic to Aspirin?*

Yes

Please select which treatment(s) you will be receiving in Bliss Beauty at your consultation*

Elemis Biotec Facial

Elemis Hands on Facial

Neostrata Glycolic Peel (please note a patch test is required 24 hours before this treatment if you have not had it before)

Frangipani Body Scrub

Massage

Bliss Deep Cleansing Back Treatment

Ear Candling

Reflexology

Manicure/Pedicure

Callus Peel

Tinting (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 Tan

Eyelash Application

Make Up

I 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.

Yes

Signature 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?

None

1-3 glasses

4-6 glasses

7-9 glasses

10+ glasses

How many hours do you usually sleep?

None

1-3 hours

4-6 hours

7-9 hours

10+ hours

Do you have a specific diet? (e.g. Vegan, Vegetarian, Keto, Paleo etc). If Yes please give details below

Yes

Details of specific diet

Do you have a healthy diet on the whole?

Yes

Do you exercise regularly?

Yes

Do you smoke?

Yes

How many cigarettes per day?

Do you drink alcohol regularly?

Yes

How many units per week?

How would you describe your energy levels?

Low

Medium

High

If you are having massage please fill out the following section

My body feels

Fine-I just want to relax

Tense and tired

Sore/my movement is restricted

Other (please state below)

Other concerns/information

Is there any particular area you would like your therapist to concentrate on during your massage? If so please give further details below

What is your pressure preference for your massage

Light

Medium

Firm

If you are having an Elemis Biotec/Hands on Facial or Neostrata peel please complete the sections below

What areas of concern do you have regarding your skin?

Acne

Blackheads

Broken Capilleries

Congestion

Dullness

Dryness

Dehydration

Excessive Oil/Shine

Fine Lines/Wrinkles

Deep Lines and Wrinkles

Loss of Elasticity

Melasma

Pigmentation

Puffiness

Rosacea

Redness

Uneven Skin Tone

Whiteheads

Other (please give details below)

Details of other skin concerns

What areas of concern do you have regarding your eye area?

Fine Lines and Wrinkles

Deep Lines and Wrinkles

Puffiness

Dark Circles

Dehydration

Other (please state below)

Details of other eye area concerns

Does your job involve you working outside?

Yes

Do you wear SPF on your face regularly?

Yes

Which of the following best describes your skin tone?

I Pale White-always burns/never tans

II White to Light Beige-tans minimally/burns easily

III Beige-Burns moderately/ tans gradually to light brown

IV Light Brown-burns minimally /tans well to moderately brown

V Moderate Brown-rarely burns /tans profusely to dark brown

VI Dark Brown or Black-never burns/ tans profusely

Are you currently using any of the following skincare?

Cleanser/Wash

Toner/Softener

Serums

Oils

Day Cream

Night Cream

Eye Cream

Exfoliators

Masks

Peels

Other (please give details below)

Details of other skincare products

What are your skin goals? What are you hoping to improve or maintain?

Which skincare brand are you currently using?

Teenage Treatments

First Name of Parent/Guardian

Surname of Parent/Guardian

Relationship to Young Person

I _________________________________ 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.

Yes

Signature Parent/Guardian

Signature Client

Covid 19 Pandemic

I 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*

Yes

I 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.*

Yes

I 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*

Yes

I confirm that I have not been around anyone with these symptoms in the past 14 days.*

Yes

I do not live with anyone who is sick or quarantined.*

Yes

To prevent the spread of contagious viruses and to help protect each other, I understand that I will have to follow the salon’s guidelines.*

Yes

I verify that I have not traveled outside the Ireland in the past 14 days to countries that have been affected by COVID-19.*

Yes

Signature*

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Covid-19 Disclaimer Form (regular clients)

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Covid-19 Disclaimer Form

Name*