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Intake & Consent Forms

Above & Beyond Hair & Body Salt Room Intake & Consent Form

Name:___________________________________________ Date:________________________

Address:______________________________ City:___________ State:____ Zip Code:________

Primary Phone:______________________ Email:______________________________________

Birthdate:_____/_____/_______Reason for your visit today:______________________________


Skin Conditions_________________________________________________________________

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

varicose veins.

___ 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

Profile/Health History.

___ 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

promotional purposes.

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________________________________________________


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