Intake & Consent Forms
Above & Beyond Hair & Body Salt Room Intake & Consent Form
Address:______________________________ City:___________ State:____ Zip Code:________
Primary Phone:______________________ Email:______________________________________
Birthdate:_____/_____/_______Reason for your visit today:______________________________
Are there any medical conditions we should be aware of? ___________________________________
Have you had a fever in the last 24 hours? (circle) YES / NO How did you hear about us?_________
Have you tried Halotherapy before? (circle one) YES / NO If yes, where? ____________________
Emergency contact: ________________Relation: ____________ Phone number:_______________
Consent and Release for Halotherapy Treatment
I am aware that there is a video camera being monitored 24/7 within the cave to ensure the safety of all our guests.
A Relaxed You, Inc. is not responsible for any lost or stolen items. There will be no Cell Phones, food, drinks, or electronics permitted
inside the cave. I agree to stay seated once the session begins and I will not pick up salt or touch the walls. I understand that all articles
of clothing must be kept on throughout the session. Halotherapy is not intended to diagnose, treat, cure, or prevent diseases and
respiratory issues. I understand that this is not a replacement for medical treatment and I have received medical clearance from a
medical professional prior to engaging in halotherapy, if I had any prior concerns. I have been advised of the possible side effects:
dry/itchy throat, nasal drip, and mild coughing—all signs of the respiratory cleansing process at A Relaxed You, Inc.
By signing below, I give consent to participate in halotherapy sessions and certify that I have read and agree to the terms listed above.
Client/Legal Guardian Signature: ____________________________________ Date: __________________________
Above & beyond Hair & Body
Microcurrent Consent & Treatment Form
treatment, please be aware of the following information and possible risks. Please initial:
___ I understand there are certain contraindications that would preclude me from receiving microcurrent
treatments, including autoimmune disorders, diabetes, embolism, epilepsy, melanoma, metal implants
including plates/pins/screws, open wounds, pacemaker use, phlebitis, pregnancy, thrombosis, and
___ I understand that the use of Botox®, Juvederm®, Restylane®, and any other injectable must be
disclosed prior to treatment.
___ I understand that microcurrent treatments involve conducting mild electrical currents through the body
and that this brings some inherent risk.
___ I understand that reactions are rare, but may include nausea, dizziness, weakness, and possible skin
reactions including redness and/or other irritations.
___ I understand that some clients report slight tingling sensations, flushing of the optic nerve, and/or a
metallic taste in the mouth during the procedure.
___ I understand that while the goal of this treatment is to improve the vitality of the skin, no specific
guarantees of the result can or have been made.
___ I understand that it is imperative to my health that I disclose all of the information requested in the Client
___ I have cited all conditions and circumstances regarding my health history, medications being taken, and
any past reactions to products or medications.
___ I understand that additional conditions could occur or be discovered during the procedure which could
affect my ability to tolerate the procedure.
___ I consent to “before and after” photographs for the purpose of documentation, potential advertising, and
I understand that if I have any concerns, I will address these with my skin care specialist. I give
permission to my skin care specialist to perform the microcurrent procedure we have discussed,
and will hold him/her and his/her staff harmless and nameless from any liability that may result
from this treatment. I have accurately answered the questions above, including all known allergies,
prescription drugs, conditions, or products I am currently ingesting or using topically. I understand
my skin care specialist will take every precaution to minimize or eliminate negative reactions as much
as possible. In the event I may have additional questions or concerns regarding my treatment, I will
consult the skin care specialist immediately. I agree that this constitutes full disclosure, and that it
supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand,
the above paragraphs and that I have had sufficient opportunity for discussion to have any questions
answered. I understand the procedure and accept the risks. I do not hold the skin care specialist,
whose signature appears below, responsible for any of my conditions that were present, but not
disclosed at the time of this procedure, which may be affected by the treatment performed today.
Client Name (Printed) _________________________________________________________________
Client Name (Signature) ____________________________________________Date:_______________
Skin care specialist________________________________________________
Jane Doe - Another Company, LLC