Confidential Body Treatment Consent Form

______________________________________________________________		________________
Client Name										Date

Referred by ___ Friend ____ Mailer ___ Walk- by   ___Yellow Pages ___Gift Certificate ___ Other 
Is this your first body treatment? ____Yes ____No
What is the reason for your visit today? __________________________________________________________________________
What other body treatments have you had? _______________________________________________________________________
Are you presently under a physician’s care for any current health problem? ____Yes ____No   What?_________________________
Are you pregnant? ___Yes ___No			If  yes, how many weeks?______ Complications? _______________________
Are you taking birth control? ___Yes  ___No	Hormone replacement? ___Yes ___No
Do you wear contact lenses? ___Yes ___No		Do you smoke? ___Yes ___No
What is your stress level? ___High ___Medium ___Low
Are you now using Accutane? ___Yes  ___No	    If so, how long have you been using it? _____________________________ 
Do you have any allergies to cosmetics, foods, seaweed, shellfish, drugs? ___Yes ___No   What?____________________________
Are you presently taking medications-prescribed or non-prescription, including aspirin? ___Yes ___No  
 If so, please list: ____________________________________________________________________________________________ 

What other products do you use presently? ________________________________________________________________________

Please indicate if you are affected by or have any of the following:
Asthma			Hysterectomy			Broken Bones where?	Pace Maker   	Sunburn	
Immune Disorders	Cardiac problems			Lower Back Problems	Hepatitis	Fungal Infections
Eczema			Metal bone pins or plates		Epilepsy			Lupus		Valley Fever
Fever Blisters		Headaches, chronic		Phlebitis, blood clots	Poor circulation    
Head /neck injury		Psychological			Sinus Problems		Herpes		
Skin Diseases		High Blood Pressure		Urinary or Kidney problems

Please explain above problems or list any other significant health concerns or issues: ___________________________________
_______________________________________________________________________________________________________

Please list the areas of the body that are of concern: _____________________________________________________________

I understand that the services offered are not a substitute for medical care, and any information provided by the Aesthetician
 is for educational purposes only and not diagnostically prescriptive in nature. I understand that the information herein is to aid the
 Aesthetician in giving better service and is completely confidential.
My signature below constitutes acknowledgement that I have read and understand the foregoing consent form and agree 
to the treatment.  I hereby give consent to ___________________ to perform a body treatment or wrap.                                                                                                                                    I hold non-liable ___________________________________________, its employees, student and affiliates thereof, for any and 
all circumstances that may occur during my treatment.  I acknowledge the information provided here is true and correct 
to the best of my knowledge as of the date of this Consent Form.  

Client Signature ____________________________________________	Date ____________________________

Therapist  Signature _____________________________________	              Date ____________________________

        
Treatment Log

Date		
Client Signature		
         Treatment