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This is the information we need in order to make your services as quick, efficient, and beneficial as possible.

First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Information

How did you hear about us? *
What time is best for phone calls?*
AM
PM
Preferred Method of Contact *
Phone Call
Text
Email

Shoe Size *

What is your preferred type of music to listen to in a relaxed setting? *
What do you do for a living? *
Work a Traditional Job or For Myself
Stay at Home Mom (let's face it, parenting is an unpaid full time job)
Student
Live my best life
Have you ever had any allergies or sensitivities to the following: *
Alpha hydroxy acids
Aspirin
Cosmetics
Fish | Marine Life | Iodine
Latex
None of the above
Nuts
Pollen
Sunscreen
Please check if you currently have or have ever been affected by any of the following: *
Cancer | Radiation
Cardiac Problems
Cold sores | Fever Blisters
Diabetes
Digestive Imbalance
Epilepsy
High blood pressure
Immune Disorders
Lupus
Metal bone, pins, or plates
Sinus problems
Skin disease
Trauma (physical, mental, verbal, other)
None of the above
Are you pregnant or lactating?*
No
Yes

List all medications you are currently taking *

List all skincare products you are currently using (including makeup) *
Preferred Skin Care Routine Type*
Check all services that you've received in the past 6 months *
Chemical Peel
Electrolysis
Facial/Cosmetic Surgery
IPL
Injections
Massage
Microcurrent
Microderm
Permanent Makeup
Sugaring
Tanning (by sun or spray tan)
Waxing
Check your top challenges you're currently working through *
Anxiety
Arthritis | Joint Pain
Eczema | Psoriasis
Hard Time Breathing
Headache | Migraine
Hyperactivity
Lack of Patience
Lack of Sleep
Low Energy
Low Immunity
Mental Exhaustion
Muscle Aches
Poor Circulation
Scars
Stress
Worry & Overthinking

Is there anything else that you would like for me to know?
First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Second Client's Information

How did you hear about us? *
What time is best for phone calls?*
AM
PM
Preferred Method of Contact *
Phone Call
Text
Email

Shoe Size *

What is your preferred type of music to listen to in a relaxed setting? *
What do you do for a living? *
Work a Traditional Job or For Myself
Stay at Home Mom (let's face it, parenting is an unpaid full time job)
Student
Live my best life
Have you ever had any allergies or sensitivities to the following: *
Alpha hydroxy acids
Aspirin
Cosmetics
Fish | Marine Life | Iodine
Latex
None of the above
Nuts
Pollen
Sunscreen
Please check if you currently have or have ever been affected by any of the following: *
Cancer | Radiation
Cardiac Problems
Cold sores | Fever Blisters
Diabetes
Digestive Imbalance
Epilepsy
High blood pressure
Immune Disorders
Lupus
Metal bone, pins, or plates
Sinus problems
Skin disease
Trauma (physical, mental, verbal, other)
None of the above
Are you pregnant or lactating?*
No
Yes

List all medications you are currently taking *

List all skincare products you are currently using (including makeup) *
Preferred Skin Care Routine Type*
Check all services that you've received in the past 6 months *
Chemical Peel
Electrolysis
Facial/Cosmetic Surgery
IPL
Injections
Massage
Microcurrent
Microderm
Permanent Makeup
Sugaring
Tanning (by sun or spray tan)
Waxing
Check your top challenges you're currently working through *
Anxiety
Arthritis | Joint Pain
Eczema | Psoriasis
Hard Time Breathing
Headache | Migraine
Hyperactivity
Lack of Patience
Lack of Sleep
Low Energy
Low Immunity
Mental Exhaustion
Muscle Aches
Poor Circulation
Scars
Stress
Worry & Overthinking

Is there anything else that you would like for me to know?
Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Third Client's Information

How did you hear about us? *
What time is best for phone calls?*
AM
PM
Preferred Method of Contact *
Phone Call
Text
Email

Shoe Size *

What is your preferred type of music to listen to in a relaxed setting? *
What do you do for a living? *
Work a Traditional Job or For Myself
Stay at Home Mom (let's face it, parenting is an unpaid full time job)
Student
Live my best life
Have you ever had any allergies or sensitivities to the following: *
Alpha hydroxy acids
Aspirin
Cosmetics
Fish | Marine Life | Iodine
Latex
None of the above
Nuts
Pollen
Sunscreen
Please check if you currently have or have ever been affected by any of the following: *
Cancer | Radiation
Cardiac Problems
Cold sores | Fever Blisters
Diabetes
Digestive Imbalance
Epilepsy
High blood pressure
Immune Disorders
Lupus
Metal bone, pins, or plates
Sinus problems
Skin disease
Trauma (physical, mental, verbal, other)
None of the above
Are you pregnant or lactating?*
No
Yes

List all medications you are currently taking *

List all skincare products you are currently using (including makeup) *
Preferred Skin Care Routine Type*
Check all services that you've received in the past 6 months *
Chemical Peel
Electrolysis
Facial/Cosmetic Surgery
IPL
Injections
Massage
Microcurrent
Microderm
Permanent Makeup
Sugaring
Tanning (by sun or spray tan)
Waxing
Check your top challenges you're currently working through *
Anxiety
Arthritis | Joint Pain
Eczema | Psoriasis
Hard Time Breathing
Headache | Migraine
Hyperactivity
Lack of Patience
Lack of Sleep
Low Energy
Low Immunity
Mental Exhaustion
Muscle Aches
Poor Circulation
Scars
Stress
Worry & Overthinking

Is there anything else that you would like for me to know?
Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Information

How did you hear about us? *
What time is best for phone calls?*
AM
PM
Preferred Method of Contact *
Phone Call
Text
Email

Shoe Size *

What is your preferred type of music to listen to in a relaxed setting? *
What do you do for a living? *
Work a Traditional Job or For Myself
Stay at Home Mom (let's face it, parenting is an unpaid full time job)
Student
Live my best life
Have you ever had any allergies or sensitivities to the following: *
Alpha hydroxy acids
Aspirin
Cosmetics
Fish | Marine Life | Iodine
Latex
None of the above
Nuts
Pollen
Sunscreen
Please check if you currently have or have ever been affected by any of the following: *
Cancer | Radiation
Cardiac Problems
Cold sores | Fever Blisters
Diabetes
Digestive Imbalance
Epilepsy
High blood pressure
Immune Disorders
Lupus
Metal bone, pins, or plates
Sinus problems
Skin disease
Trauma (physical, mental, verbal, other)
None of the above
Are you pregnant or lactating?*
No
Yes

List all medications you are currently taking *

List all skincare products you are currently using (including makeup) *
Preferred Skin Care Routine Type*
Check all services that you've received in the past 6 months *
Chemical Peel
Electrolysis
Facial/Cosmetic Surgery
IPL
Injections
Massage
Microcurrent
Microderm
Permanent Makeup
Sugaring
Tanning (by sun or spray tan)
Waxing
Check your top challenges you're currently working through *
Anxiety
Arthritis | Joint Pain
Eczema | Psoriasis
Hard Time Breathing
Headache | Migraine
Hyperactivity
Lack of Patience
Lack of Sleep
Low Energy
Low Immunity
Mental Exhaustion
Muscle Aches
Poor Circulation
Scars
Stress
Worry & Overthinking

Is there anything else that you would like for me to know?
Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Information

How did you hear about us? *
What time is best for phone calls?*
AM
PM
Preferred Method of Contact *
Phone Call
Text
Email

Shoe Size *

What is your preferred type of music to listen to in a relaxed setting? *
What do you do for a living? *
Work a Traditional Job or For Myself
Stay at Home Mom (let's face it, parenting is an unpaid full time job)
Student
Live my best life
Have you ever had any allergies or sensitivities to the following: *
Alpha hydroxy acids
Aspirin
Cosmetics
Fish | Marine Life | Iodine
Latex
None of the above
Nuts
Pollen
Sunscreen
Please check if you currently have or have ever been affected by any of the following: *
Cancer | Radiation
Cardiac Problems
Cold sores | Fever Blisters
Diabetes
Digestive Imbalance
Epilepsy
High blood pressure
Immune Disorders
Lupus
Metal bone, pins, or plates
Sinus problems
Skin disease
Trauma (physical, mental, verbal, other)
None of the above
Are you pregnant or lactating?*
No
Yes

List all medications you are currently taking *

List all skincare products you are currently using (including makeup) *
Preferred Skin Care Routine Type*
Check all services that you've received in the past 6 months *
Chemical Peel
Electrolysis
Facial/Cosmetic Surgery
IPL
Injections
Massage
Microcurrent
Microderm
Permanent Makeup
Sugaring
Tanning (by sun or spray tan)
Waxing
Check your top challenges you're currently working through *
Anxiety
Arthritis | Joint Pain
Eczema | Psoriasis
Hard Time Breathing
Headache | Migraine
Hyperactivity
Lack of Patience
Lack of Sleep
Low Energy
Low Immunity
Mental Exhaustion
Muscle Aches
Poor Circulation
Scars
Stress
Worry & Overthinking

Is there anything else that you would like for me to know?
Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Information

How did you hear about us? *
What time is best for phone calls?*
AM
PM
Preferred Method of Contact *
Phone Call
Text
Email

Shoe Size *

What is your preferred type of music to listen to in a relaxed setting? *
What do you do for a living? *
Work a Traditional Job or For Myself
Stay at Home Mom (let's face it, parenting is an unpaid full time job)
Student
Live my best life
Have you ever had any allergies or sensitivities to the following: *
Alpha hydroxy acids
Aspirin
Cosmetics
Fish | Marine Life | Iodine
Latex
None of the above
Nuts
Pollen
Sunscreen
Please check if you currently have or have ever been affected by any of the following: *
Cancer | Radiation
Cardiac Problems
Cold sores | Fever Blisters
Diabetes
Digestive Imbalance
Epilepsy
High blood pressure
Immune Disorders
Lupus
Metal bone, pins, or plates
Sinus problems
Skin disease
Trauma (physical, mental, verbal, other)
None of the above
Are you pregnant or lactating?*
No
Yes

List all medications you are currently taking *

List all skincare products you are currently using (including makeup) *
Preferred Skin Care Routine Type*
Check all services that you've received in the past 6 months *
Chemical Peel
Electrolysis
Facial/Cosmetic Surgery
IPL
Injections
Massage
Microcurrent
Microderm
Permanent Makeup
Sugaring
Tanning (by sun or spray tan)
Waxing
Check your top challenges you're currently working through *
Anxiety
Arthritis | Joint Pain
Eczema | Psoriasis
Hard Time Breathing
Headache | Migraine
Hyperactivity
Lack of Patience
Lack of Sleep
Low Energy
Low Immunity
Mental Exhaustion
Muscle Aches
Poor Circulation
Scars
Stress
Worry & Overthinking

Is there anything else that you would like for me to know?
Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Information

How did you hear about us? *
What time is best for phone calls?*
AM
PM
Preferred Method of Contact *
Phone Call
Text
Email

Shoe Size *

What is your preferred type of music to listen to in a relaxed setting? *
What do you do for a living? *
Work a Traditional Job or For Myself
Stay at Home Mom (let's face it, parenting is an unpaid full time job)
Student
Live my best life
Have you ever had any allergies or sensitivities to the following: *
Alpha hydroxy acids
Aspirin
Cosmetics
Fish | Marine Life | Iodine
Latex
None of the above
Nuts
Pollen
Sunscreen
Please check if you currently have or have ever been affected by any of the following: *
Cancer | Radiation
Cardiac Problems
Cold sores | Fever Blisters
Diabetes
Digestive Imbalance
Epilepsy
High blood pressure
Immune Disorders
Lupus
Metal bone, pins, or plates
Sinus problems
Skin disease
Trauma (physical, mental, verbal, other)
None of the above
Are you pregnant or lactating?*
No
Yes

List all medications you are currently taking *

List all skincare products you are currently using (including makeup) *
Preferred Skin Care Routine Type*
Check all services that you've received in the past 6 months *
Chemical Peel
Electrolysis
Facial/Cosmetic Surgery
IPL
Injections
Massage
Microcurrent
Microderm
Permanent Makeup
Sugaring
Tanning (by sun or spray tan)
Waxing
Check your top challenges you're currently working through *
Anxiety
Arthritis | Joint Pain
Eczema | Psoriasis
Hard Time Breathing
Headache | Migraine
Hyperactivity
Lack of Patience
Lack of Sleep
Low Energy
Low Immunity
Mental Exhaustion
Muscle Aches
Poor Circulation
Scars
Stress
Worry & Overthinking

Is there anything else that you would like for me to know?
Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Information

How did you hear about us? *
What time is best for phone calls?*
AM
PM
Preferred Method of Contact *
Phone Call
Text
Email

Shoe Size *

What is your preferred type of music to listen to in a relaxed setting? *
What do you do for a living? *
Work a Traditional Job or For Myself
Stay at Home Mom (let's face it, parenting is an unpaid full time job)
Student
Live my best life
Have you ever had any allergies or sensitivities to the following: *
Alpha hydroxy acids
Aspirin
Cosmetics
Fish | Marine Life | Iodine
Latex
None of the above
Nuts
Pollen
Sunscreen
Please check if you currently have or have ever been affected by any of the following: *
Cancer | Radiation
Cardiac Problems
Cold sores | Fever Blisters
Diabetes
Digestive Imbalance
Epilepsy
High blood pressure
Immune Disorders
Lupus
Metal bone, pins, or plates
Sinus problems
Skin disease
Trauma (physical, mental, verbal, other)
None of the above
Are you pregnant or lactating?*
No
Yes

List all medications you are currently taking *

List all skincare products you are currently using (including makeup) *
Preferred Skin Care Routine Type*
Check all services that you've received in the past 6 months *
Chemical Peel
Electrolysis
Facial/Cosmetic Surgery
IPL
Injections
Massage
Microcurrent
Microderm
Permanent Makeup
Sugaring
Tanning (by sun or spray tan)
Waxing
Check your top challenges you're currently working through *
Anxiety
Arthritis | Joint Pain
Eczema | Psoriasis
Hard Time Breathing
Headache | Migraine
Hyperactivity
Lack of Patience
Lack of Sleep
Low Energy
Low Immunity
Mental Exhaustion
Muscle Aches
Poor Circulation
Scars
Stress
Worry & Overthinking

Is there anything else that you would like for me to know?
Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Information

How did you hear about us? *
What time is best for phone calls?*
AM
PM
Preferred Method of Contact *
Phone Call
Text
Email

Shoe Size *

What is your preferred type of music to listen to in a relaxed setting? *
What do you do for a living? *
Work a Traditional Job or For Myself
Stay at Home Mom (let's face it, parenting is an unpaid full time job)
Student
Live my best life
Have you ever had any allergies or sensitivities to the following: *
Alpha hydroxy acids
Aspirin
Cosmetics
Fish | Marine Life | Iodine
Latex
None of the above
Nuts
Pollen
Sunscreen
Please check if you currently have or have ever been affected by any of the following: *
Cancer | Radiation
Cardiac Problems
Cold sores | Fever Blisters
Diabetes
Digestive Imbalance
Epilepsy
High blood pressure
Immune Disorders
Lupus
Metal bone, pins, or plates
Sinus problems
Skin disease
Trauma (physical, mental, verbal, other)
None of the above
Are you pregnant or lactating?*
No
Yes

List all medications you are currently taking *

List all skincare products you are currently using (including makeup) *
Preferred Skin Care Routine Type*
Check all services that you've received in the past 6 months *
Chemical Peel
Electrolysis
Facial/Cosmetic Surgery
IPL
Injections
Massage
Microcurrent
Microderm
Permanent Makeup
Sugaring
Tanning (by sun or spray tan)
Waxing
Check your top challenges you're currently working through *
Anxiety
Arthritis | Joint Pain
Eczema | Psoriasis
Hard Time Breathing
Headache | Migraine
Hyperactivity
Lack of Patience
Lack of Sleep
Low Energy
Low Immunity
Mental Exhaustion
Muscle Aches
Poor Circulation
Scars
Stress
Worry & Overthinking

Is there anything else that you would like for me to know?
Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Information

How did you hear about us? *
What time is best for phone calls?*
AM
PM
Preferred Method of Contact *
Phone Call
Text
Email

Shoe Size *

What is your preferred type of music to listen to in a relaxed setting? *
What do you do for a living? *
Work a Traditional Job or For Myself
Stay at Home Mom (let's face it, parenting is an unpaid full time job)
Student
Live my best life
Have you ever had any allergies or sensitivities to the following: *
Alpha hydroxy acids
Aspirin
Cosmetics
Fish | Marine Life | Iodine
Latex
None of the above
Nuts
Pollen
Sunscreen
Please check if you currently have or have ever been affected by any of the following: *
Cancer | Radiation
Cardiac Problems
Cold sores | Fever Blisters
Diabetes
Digestive Imbalance
Epilepsy
High blood pressure
Immune Disorders
Lupus
Metal bone, pins, or plates
Sinus problems
Skin disease
Trauma (physical, mental, verbal, other)
None of the above
Are you pregnant or lactating?*
No
Yes

List all medications you are currently taking *

List all skincare products you are currently using (including makeup) *
Preferred Skin Care Routine Type*
Check all services that you've received in the past 6 months *
Chemical Peel
Electrolysis
Facial/Cosmetic Surgery
IPL
Injections
Massage
Microcurrent
Microderm
Permanent Makeup
Sugaring
Tanning (by sun or spray tan)
Waxing
Check your top challenges you're currently working through *
Anxiety
Arthritis | Joint Pain
Eczema | Psoriasis
Hard Time Breathing
Headache | Migraine
Hyperactivity
Lack of Patience
Lack of Sleep
Low Energy
Low Immunity
Mental Exhaustion
Muscle Aches
Poor Circulation
Scars
Stress
Worry & Overthinking

Is there anything else that you would like for me to know?
Parent or Guardian's Email Address

Email
Check to receive information, news, and discounts by e-mail.
A signed copy of this waiver will be sent to the email address you provide.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Client Informed Consent, Agreement, and Liability Waiver

By typing my full name, I consent to and authorize Your Bliss Skin & Body Care to perform skin exfoliation, facials, hair removal, tweezing, microdermabrasion, chemical peels, body treatments, makeup application, and other related skincare services. I understand that with any of these treatments, certain risks are involved and that any complications, allergies, or side effects from known or unknown causes could occur. I freely assume these risks. I understand that these services are NOT a substitute for medical treatment, examination, or medications and that it is recommended to work with my primary caregiver for any condition that I may have. Above, I have informed the aesthetician/student of all of my known physical and medical conditions and medications, and I will keep her updated on any changes in my health status. I am aware that heated herbal compresses may be used during the session, and I will inform the therapist if I have heat sensitivities or allergies. I understand that all of the information regarding my health history, the records of my sessions, and other personal information related to the session will remain in complete confidence. By inputting my name, I agree to HOLD HARMLESS Your Bliss Skin & Body Care and the therapists and supervising instructors associated with services rendered today and ANY future sessions that I receive at this clinic. *
YBSBC Cancellation Policy

This policy is in place simply because we recognize that everyone's time is valuable. We understand that life happens & hope you remember that your estheticians have lives too. Our appointment scheduling software is set to send two (2) notifications: A confirmation request sent 24-hours prior to appointment time A secondary reminder sent 12-hours prior to appointment time All appointments require: A Card on File Response to the Confirmation Request Charges to Cards on File will be executed as follows: Appointments with no response to the confirmation request, no communication to Your Bliss Skin & Body Care prior to appointment time, and no show will result in 100% charge of service price at time of appointment Appointments with response requesting to cancel or reschedule and/or communication with Your Bliss Skin & Body Care to cancel or reschedule within 12-24 hours of appointment time will result in 50% charge of service price at time of appointment (this charge will apply to your rescheduled service) Appointments with response requesting to reschedule or cancel within 12 hours of appointment time will result in 50% charge of service price at time of appointment (this charge will not apply to any future services) Any client whose card is being charged will receive a courtesy message to alert that a charge will be applied All appointments cancelled or rescheduled prior to appointment notification cycle will not be charged We understand that emergencies and unavoidable circumstances can occur, causing you to reschedule or cancel your appointment. Any cancellation or reschedule request that fits these circumstances will be reviewed by management and either charged or waived on a case-by-case basis. Avoidable circumstances are understood, and will be charged based on the aforementioned policy. Clients who cancel late or no-show two (2) times in a 12 -month period may not be allowed to schedule appointments in the future. By typing your name, you are acknowledging that you have read, understand, and agree to this Cancellation and No Show Policy.
Click to customize section title

By initialing below, you authorize Your Bliss Skin Care, DBA Your Bliss Skin & Body Care or YBSBC, to save your credit card on file for agreed upon purchases related to this establishment. You are also acknowledging that you understand that your information will be saved to file for future transactions on your account and will not be charged without your permission. In the case of a no-show appointment, you authorize YBSBC to charge your card for 50% of your appointment cost after being alerted of said charge via text. Initialing below serves as permission to charge the no-show fee when you no-show for your appointment


Initial Here *
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

How did you hear about us? *
What time is best for phone calls?*
AM
PM
Preferred Method of Contact *
Phone Call
Text
Email

Shoe Size *

What is your preferred type of music to listen to in a relaxed setting? *
What do you do for a living? *
Work a Traditional Job or For Myself
Stay at Home Mom (let's face it, parenting is an unpaid full time job)
Student
Live my best life
Have you ever had any allergies or sensitivities to the following: *
Alpha hydroxy acids
Aspirin
Cosmetics
Fish | Marine Life | Iodine
Latex
None of the above
Nuts
Pollen
Sunscreen
Please check if you currently have or have ever been affected by any of the following: *
Cancer | Radiation
Cardiac Problems
Cold sores | Fever Blisters
Diabetes
Digestive Imbalance
Epilepsy
High blood pressure
Immune Disorders
Lupus
Metal bone, pins, or plates
Sinus problems
Skin disease
Trauma (physical, mental, verbal, other)
None of the above
Are you pregnant or lactating?*
No
Yes

List all medications you are currently taking *

List all skincare products you are currently using (including makeup) *
Preferred Skin Care Routine Type*
Check all services that you've received in the past 6 months *
Chemical Peel
Electrolysis
Facial/Cosmetic Surgery
IPL
Injections
Massage
Microcurrent
Microderm
Permanent Makeup
Sugaring
Tanning (by sun or spray tan)
Waxing
Check your top challenges you're currently working through *
Anxiety
Arthritis | Joint Pain
Eczema | Psoriasis
Hard Time Breathing
Headache | Migraine
Hyperactivity
Lack of Patience
Lack of Sleep
Low Energy
Low Immunity
Mental Exhaustion
Muscle Aches
Poor Circulation
Scars
Stress
Worry & Overthinking

Is there anything else that you would like for me to know?
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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