Treatments | Bliss Beauty-Salon-Spa Kilkenny

Date*

Date of Appointment*

First Name*

Surname*

Age*

Email*

Confirm Email*

Address*

Mobile Number*

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

No

Details of allergies

Are you allergic to Aspirin?*

Yes

No

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

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 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

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*

Captcha

Elemis Face | Touch

Elemis Face | Technology

Neostrata Performance Glycolic Peels

Body Therapy

Massage Therapy and Holistic Treatments

Reflexology

Hand and Nail Treatments

Pedicures and Foot Treatments

Eye Care and Eye Treatments

Sunless Tanning

Waxing

Make Up Application

Pregnancy Treatments

If you are having a biotec/hands on facial/massage/reflexology please fill out the following section (otherwise skip to the next section)

If you are having massage please fill out the following section

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

Teenage Treatments

Covid 19 Pandemic

Bliss Beauty

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