The Experiece Facial Ritual
Client Intake Form

First name

Last name

Phone

Emergency Contact (Name + Phone Number)

WHAT IS YOUR AGE RANGE?

0-20

21-39

40-59

60+

DO YOUR SUFFER FROM ANY KNOWN ALLERGIES? (environmental, scent, topical, food)

HAVE YOU RECEIVED A FACIAL OR ANY TYPE OF ENERGY WORK BEFORE?

WHY ARE YOU INTERESTED IN THE EXPERIENCE FACIAL RITUAL AT THIS TIME AND WHAT ARE YOU HOPING TO ACHIEVE FROM OUR TIME TOGETHER? (physically, emotionally, spiritually or other)

DO YOU FEEL ANY ENERGY STUCK OR ANY STAGNATION IN YOUR BODY? IF YES, WHERE?

YOUR INFRADIAN RHYTHM: a 28-31 day cycle that regulates the menstrual cycle. ARE YOU AWARE OF WHICH PART OF YOUR MOON CYCLE YOU ARE IN AT THE TIME OF YOUR SERVICE? (This will allow me to properly prepare your herbal foot tea and ritual oil blend)

MENSTRUATION ( 1 - 5 days of your period)

FOLLICULAR ( 6 to 13 days after your period)

OVULATORY (14-17 days after your period in the middle of your cycle)

LUTEAL (18 to 28-31 days between ovulation and your period)

NO LONGER (pregnancy/ historectomy / menopause / other)

HOW WOULD YOU DESCRIBE YOUR CURRENT STRESS LEVELS? NONE/LOW/MEDIUM/HIGH

HAVE YOU HAD ANY MEDICAL CONCERNS THAT I SHOULD BE AWARE OF? (including the use of retinoid medications, heart conditons, cancer, autoimmune disorders, major surgery)

WHICH FACIAL PRODUCTS ARE YOU CURRENTLY USING AS A PART OF YOUR SKINCARE ROUTINE?

HOW DID YOU HEAR ABOUT NORTHERN ALKEMI?

DO YOU GIVE PERMISSION FOR PICTURES & VIDEOS FOR THE PURPOSE OF DOCUMENTATION, POTENTIAL ADVERTISING AND PROMOTIONAL PURPOSES?

Yes

Client Acknowledgement: YOUR SATISFACTION AND SAFETY IS MY NUMBER ONE PRIORITY TO ENSURE YOUR WELLBEING BEFORE, DURING AND AFTER YOUR TREATMENT. PLEASE BE AWARE OF THE FOLLOWING INFORMATION AND CHECK MARK BELOW:

I have agreed to receive The Experience Facial Ritual from Charmaine Holan, of Northern Alkemi.

I understand that my treatment is conducted on a private property (158 Sonora Crescent, Fort Saskatchewan), and that all reasonable efforts have been made to ensure it is safe and comfortable for my attendance.

I’ve shared all relevant details about my health history, including any medications I’m currently taking and any past reactions to products or medications that might affect or interfere with this treatment.

I accept full liability in the very unlikely event of my personal injury while on the above mentioned premises. I also accept full responsibility and liability for any event that may occur because of my personal choices or actions undertaken as a result of my healing session.

I understand that there may be other factors that could affect how well I tolerate the treatment. I’m also aware that there are some risks involved, and in very rare cases, I might experience skin irritation or discomfort.

By proceeding, you confirm that you fully understand the service you’ve requested and the associated risks. You’ve shared any relevant pre-existing conditions, allergies, or sensitivities with your service provider. Northern Alkemi and the service provider are not responsible for any dissatisfaction, discomfort, injury, or damage that may occur as a result of the service.

Date

Year

Month

Day

Signature

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The Experiece Facial Ritual Client Intake Form

The Experiece Facial Ritual
Client Intake Form