CONTACT

Instagram Handel

Follow us @ritualwellnesspdx

Email

Would you like to hear about our sales and specials?

Profession

SKINCARE

What are your immediate concerns:

Skin Tone . Pore Size . Aging . Sensitivity . Redness/Rosacea . Acne/Breakouts . Other...

What Is your skin type:

Oily . Dry . Normal .Combination . Sensitive

Tell us about your routine, what brands are you using and how frequently?

Cleansers . Exfoliation . Serums . Oils . Moisturizers . SPF . Masques. Lip Care. Eye Cream. Toner.

Which do you prefer

When was your last facial treatment and what did you enjoy most about it

Medical History

Please list all that a apply

Pregnant/Recently Pregnant . Psoriasis . Contagious Skin Disorders . Recent Surgery . Eczema . Cancer . Varicose Veins . Heart Disease . Asthma . Hypoglycemia . Breast Feeding . Claustrophobia . Epilepsy . Thyroid Disease . Autoimmune Disorder . Diabetes .

list all allergies

Are you a smoker

Current stress level

1 being very low stress

If you have a menstrual cycle, when was your last and are they regular

Please list all medications, herbs, and supplements and reason for taking them

Do you have any dietary philosophies

Vegan . Vegetarian . Dairy Free . Gluten Free . None/Other

Approximate daily water and coffee intake in oz.

THERE ARE SOME DRUGS AND PRODUCTS THAT HAVE SEVERE CONTRAINDICATIONS FOR SOME TYPES OF FACIAL TREATMENTS. PLEASE NOTE IF YOU HAVE USED ANY OF THE FOLLOWING IN THE PAST 6 MONTHS

Accutane . Blood Thinners . Retin-A . Chemical Peel . Differin . Laser Treatments . Retinol . Steroids . Antibiotics

Please note our extended list of add on beauty boosters for todays service or future services. Please put a check next to any that you want to know more about...

CAN BE ADDED TODAY: Microdermabrasion . CBD Anti Inflammatory Treatment . TDP Detox Foot Treatment . Sinus Acupressure . Facial Cryotherapy . Organic Custom Peel . High Frequency . Line Filler And Neck Lift (non invasive) CAN BE ADDED TO FUTURE SERVICES: Brow Wax . Brow Tint . Hot Oil Scalp Massage . Gua Sha Facial Massage . Foot Reflexology . Hand + Arm Treatment . Dermaplane Treatment . Facial Cupping

CONSENT FOR SERVICE

I hereby consent to and authorize Ritual Wellness to perform the procedure I have booked. I have voluntarily elected to undergo this treatment/procedure fully understanding the nature and purpose of this treatment, along with the risks and hazards involved. Although it is impossible to list every potential risk and complication, I am informed of possible benefits, risks, and complications. I also recognize there are no guaranteed results and that independent results are dependent upon age, skin condition, and lifestyle and that there is the possibility I may require further treatments to obtain the expected results at an additional cost. I have also, to the best of my knowledge, given an accurate account of my medical history, including all known allergies or prescription drugs or products I am currently ingesting or using topically. I have read and fully understand this agreement and all information detailed above. I understand the procedure and accept the risks. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I do not hold the therapist, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this procedure and future treatments. Cancelation: I am aware of Ritual’s 24hr cancelation/rescheduling policy + waver I signed when booking my appointment online with credit card. As well as, that all service + product sales are final.

Please Type Your Full Name To Sign

Specials/Groupons: I acknowledge that Ritual Wellness has recently undergone a name change (formerly gincare) and all my future treatments will be booked with Ritual Wellness as my service provider. All specials are for one time use only, and groupons are for first time clients only and should be booked with GinCare Wholistic Wellness.

Please Type Your Full Name To Sign