Client Intake Form

Please fill out the following form.

First name

Last name

Email

Phone

Gender

Male

Female

Date of birth

Month

Day

Year

Have you been hospitalized in the last 12 months?

No

Yes

Are you suffering from a medical condition, illness or injury?

No

Yes

Have you ever been waxed before

Yes

No

Are you using any of the following products or ingredients orally or topically? (Check all that apply)

If you selected any of the options above, please complete. (Please include Product/Medication name, Purpose and Frequency)

Do any of the following apply to you?

Please explain any condition you marked

Do you have any known allergies?

Do you currently have any cold sores/blisters? If yes, you will need to reschedule your treatment

Yes

No

Do you smoke?

Yes

No

Have you ever experienced any adverse reactions to waxing or makeup?

Yes

No

If yes, please explain below.

Do you consume alcohol?

Yes

No

Please list any medications your currently taking

Which best describes your skin?

Have you had a body or facial wax within the past two weeks?

Yes

No

How does your skin heal? (Check all that apply)

Fast

Scars

Slow

Pigments

I hereby consent to and authorize PINK MANSION BEAUTY to perform the following procedure(s):

By signing below, I agree to the following:

I have completed this form to the best of my ability and knowledge. I understand that my data will be strictly confidential. This clinic does not sell, share, or resell information. I agree to inform my esthetician of any changes in the above information. I agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liability toward my skin care professional and/or the salon for any injury or damages incurred due to any misrepresentation of my health.

I have voluntarily consent to photos/videos during your service for promotional and educational purposes)

I have voluntarily elected to undergo this treatment/procedure after the nature and purpose of this treatment have been explained to me.

I understand and acknowledge that there are risks involved with the treatment I will be receiving. Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications, and I have had the opportunity to ask questions regarding these risks and other possible 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 a possibility I may require further treatments of the treated areas to obtain the expected results at an additional cost.

I have read and understood the post-treatment home care instructions. I understand how important it is to follow all instructions given to me for post-treatment care. In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult the esthetician immediately.

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. I agree I will assume the risk and full responsibility for any and all injuries, losses, side effects, or damages that might occur to me while I am undergoing this procedure. I do not hold the esthetician, BARBIE MELVIN, responsible for any of my conditions that were present, but not disclosed at the time of this skincare procedure, which may be affected by the treatment performed today.

Initials

Signature