Pre-Service Form – Bliss Dermacare

Your Information

Full Name *

Appointment Date *

Phone Number *

Email Address *

Age Verification & Guardian Consent

Client Age Category *

I am 18 years of age or older I am under 18 (parent/guardian consent required)

Skin Health & Conditions

Do you have any active skin conditions? *

Known product allergies or sensitivities *

Medical History

Do any of these apply to you? *

Pregnant or nursing Currently undergoing chemotherapy or radiation Blood clotting disorder or on blood thinners Recent surgery (within 3 months) Epilepsy or seizure disorders None of the above

Current medications or supplements (especially acne/retinoid medications) *

Recent Treatments

Have you had any of these treatments in the past 7 days? *

Waxing or hair removal Chemical peels or strong exfoliation Microdermabrasion or laser treatments Botox or injectable treatments Retinoid or vitamin A products

Pre-Service Preparation

Alcohol Consumption *

Alcohol thins the blood and can affect treatment outcomes. Please avoid alcohol for 24 hours before your appointment.

I have not consumed alcohol in the past 24 hours I have consumed alcohol in the past 24 hours

Skin Preparation *

Please ensure clean, dry skin free of lotions, oils, deodorant, or makeup.

My skin is clean and dry No lotions, oils, fragrances, or makeup applied I have practiced proper hygiene before arrival

Bodily Fluids & Hygiene Acknowledgment *

For the health and safety of all clients and our esthetician, we require:

I understand that if there are any active infections, communicable diseases, open wounds with drainage, or other hygiene concerns, services will be refused. I have no such conditions.

Conduct & Appointment Expectations

By proceeding with your appointment, you agree to the following:

Respectful conduct toward the esthetician and facility
Appropriate attire and personal hygiene
No inappropriate touching or behavior during the treatment
Compliance with all health and safety protocols

During & After Appointment *

I understand the treatment area will be exposed during my service. I acknowledge professional draping and boundaries will be maintained. I will inform the esthetician immediately of any discomfort.

Post-Treatment Care *

I will follow post-treatment care instructions provided by the esthetician, including avoiding sun exposure, hot water, tight clothing, and strenuous activity for 24-48 hours.

Right to Refuse Service

Bliss Dermacare reserves the right to refuse or terminate service for:

Any communicable diseases or active infections
Open wounds, severe sunburn, or compromised skin barrier
Under the influence of alcohol or drugs
Disruptive, disrespectful, or inappropriate behavior
Skin conditions that contraindicate the requested service
Non-compliance with health and safety protocols
Failure to disclose relevant medical information

If service is refused, payment will be refunded in full.

I acknowledge that Bliss Dermacare has the right to refuse service and understand the conditions listed above.

Health & Safety Agreement *

I have accurately completed this pre-service questionnaire and disclosed all relevant health information. I understand that the esthetician will use their professional judgment to determine if any treatments are contraindicated based on my responses. I assume all risks associated with my service and release Bliss Dermacare from any liability for adverse reactions related to non-disclosed conditions or failure to follow pre- and post-treatment care instructions.

I understand that esthetic treatments are not medical procedures and do not replace medical advice from licensed physicians.

I have read and agree to all terms and conditions outlined in this pre-service questionnaire.

Pre-Service Questionnaire