Facial Client Intake Form

COVID-19 Liability Release Waiver
**Signature Required Prior to Every Scheduled Appointment**

Due to the 2019-2020 outbreak of the novel Coronavirus (COVID-19), BodyWorks, Asian Bodywork Therapies and HealingGround are taking extra precautions with the care of every client to include health history review andenhanced sanitation/disinfection procedures in accordance with the Wisconsin Department of Safety and Professional Services guidance.

Symptoms of COVID-19 include:

Fever
Fatigue
Dry Cough
Difficulty Breathing

I agree to the following: *
[ ] I understand the above symptoms and affirm that I, as well as all household members, do not currently have, nor have experienced the symptoms listed above WITHIN THE LAST 14 DAYS.
[ ] I affirm that I, as well as all household members, have not been diagnosed with COVID-19 WITHIN THE PAST 30 DAYS.
[ ] I affirm that I, as well as all household members, have not knowingly been exposed to anyone diagnosed with COVID-19 WITHIN THE PAST 30 DAYS.
[ ] I affirm that I, as well as all household members, have not traveled outside of the country, or to any cityconsidered to be a "hot spot" for COVID-19 infections WITHIN THE PAST 30 DAYS.
[ ] I understand that Phyllis Wolf, BodyWorks, Asian Bodywork Therapies LLC and HealingGround cannot beheld liable for any exposure to the COVID-19 virus caused by on this form or the health history provided by each client.

BodyWorks, Asian Bodywork Therapies LLC and HealingGround are following these enhanced procedures to prevent the spread of COVID-19:

Prepayment for services available or electronic invoicing if clients prefer contactless checkout
Additional time included between appointments to prevent client contact with each other
Guests accompanying those scheduled for services discouraged
Each client required to wash hands upon arrival and before leaving
Your therapist will thoroughly clean hands and wear nitrile gloves during all treatments
Your therapist will wear a clean set of arm coverings, cloth mask, and an apron for each client
All product bottles used during treatment will be placed on the trolley for disinfection and disposable items will be used when possible
All surfaces will be wiped thoroughly with hospital grade disinfectant before and after each clientaccording to the manufacturer's directions.

By signing below, I agree to each statement above and release Phyllis Wolf, BodyWorks, Asian Bodywork Therapies LLC and HealingGround from any and all liability for the unintentional exposure or harm due to COVID-19.
Phyllis Wolf agrees to abide by these standards and affirms the same.

ClientName *

First Name Middle Name Last Name

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Client Birth Date *

Month Day Year

AGE *

Home Phone

Area Code Phone Number

Work Phone

Area Code Phone Number

Cell Phone

Area Code Phone Number

Client E-Mail *

How may we contact you? (Check all that apply)

email text message telephone

What is your family background/ethnicity? (Some skin types are more sensitive than others)

How did you hear about BodyWorks @ HealingGround?

Are you in good health?

Yes No

Do you have a history of cold sores?

Are you taking any medication? If yes, please list medication and dosage per day

Do you have any allergies? (Latex, aspirin, shellfish, etc.) If so please list them

Do you take vitamins/herbs regularly? If so please list them.

Have you had any recent surgeries? If so please list date and type along with any complications.

Any serious illness or disease? If yes please list.

Does your diet include any of the following?

Dairy Peanuts Wheat Fruit Soy Sugar

What is your daily intake of the following (in cups)

Water Coffee Tea Soda

How often do you drink alcoholic beverages?

Do you use tobacco products

Yes No

Do you take birth control pills or hormones? If yes please list

Are you pregnant, trying to become pregnant or lactating?

Yes No

Do you now or have you ever taken Accutane? If so indicate when.

Are you using Retin-A or any topical retinoids? If so indicate when.

What best describes your skin?

Oily Dry Sensitive Combination Normal

Which of the following would you like to improve?

Acne Enlarged Pores Scarring Blackheads Wrinkles/Signs of Aging Pigmentaion issues Clogged Pores

Do you currently or have you ever used any of the following on your face?

What products and brands of skincare are you currently using?

Do you sunburn easily?

Yes No

Do you tan easily?

Yes No

Do you use a tanning bed?

Yes No

Do you have any history of skin cancer or malignancies? If so include dates and types.

What are your skincare goals?

I understand that there are certain risks associated with facial services. I hereby hold the company and its associates harmless and waive any and all liability that may arise from any services and/or products from BodyWorks. I have fully disclosed all information required on this form including allergies, medications, any health issues and previously performed services elsewhere. Enter your full legal name and the date below affirming that you have read and understand this.

Enter the message as it's shown *

Facial Client Information

Medical History

Skin Care History & Analysis