Consulation Form

First Name

Last Name

Address

Address line 2

Town

County

Post Code

Email *

Mobile Number *

Emergency Contact Name & Number *

HEALTH RECORD

Please check all that currently apply. *

  •   Eye conditions - Blepharitis / Eye infections

  •   Pregnant or Postpartum

  •   Menopause

  •   Asthma

  • Cancer 

  • Diabetes 

  •   Headaches

  •   High / Low Blood Pressure

  •   Depression

  • Anxiety

  •   Bruise Easily

  •   Used Retin -A within the past month?

  •   Hormone Treatment

  •   None of these apply

Please list any other current health conditions not mentioned above

Please list any medications, supplements, or herbal remedies you currently take:

Would you know if your conditions require a doctor to agree with your required treatment? Do you have any medical conditions, injuries or sensitivities that we should be aware of?

Please give a full list of allergies or sensitivities:

At time of completing this form what is your health status?

Full Name of your Doctor *

Doctor's Address *

What do you consider your skin type?

  •   Normal

  •   Oily

  •   Ache

  •   Dry

  •   Aging

  •   Combination

  •   Sensitive

  •   Rosacea 

  • Other

  • What is your daily skin care regimen? (only applicable for facial treatments)

  • Do you have any specific areas of tension, pain or discomfort you would like addressed?

  • What level of pressure do you typically prefer (light, medium, deep)?

  • What is your stress level right now?

  • Low

  • Average

  • Somewhat Stressed

  • Very Stressed

Terms and Conditions

By SUBMITTING THIS FORM, you agree to the following:

  1.   I give my permission to receive in-salon services by bare.

  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 medical treatment 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

  •   Exacerbation of undiscovered injury

  1. I, therefore, release bare. and the individual therapist from all liability concerning these injuries that may occur during the treatment session as I am aware of the risks.

  2. I understand the importance of informing my therapist of all medical conditions and medications I am taking, and to let the therapist know about any changes to these at any ongoing appointments.

  3.   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.

  4.   I am aware that our appointments are subject to late cancellations due to ill health by either party.

  5.   Please keep in mind that, while we follow all recommended safety precautions, you are visiting our facilities at your own risk. Further, we can refuse service to anyone if we believe that any of the information is untrue, or if anyone refuses to provide requested information.

  6. Signature * Date*