Copy of intake form pro 1

Client Information

First Name

Last Name

Email Address

Date of Submission

Phone Number

Date of Birth (MM/DD/YYYY)

Street Address

Emergency Contact

Full Name

Phone

Relationship

Health Information

Do you have any allergies?

Yes No

Do you have skin sensitivities or reactions to beauty products?

Yes No

Are you currently pregnant or breastfeeding?

Yes No

Have you recently undergone any surgeries or medical treatments?

Yes No

Are you currently taking any medication that may affect your skin or hair?

Yes No

Do you have any chronic skin or medical conditions?

Yes No

If you answered “Yes” to any of the questions above, please provide details:

Previous Beauty Services

Have you previously received beauty treatments or procedures?

Yes No

Have you ever experienced adverse reactions to beauty products or procedures?

Yes No

If you selected “Yes” above, please provide details:

Client Consent and Acknowledgements

Permission to use photos/videos for promotional purposes:

Yes No

Permission to receive notifications/offers via email or SMS:

Yes No

Required Legal Acknowledgements

By submitting this form, you acknowledge and agree to the following statements:

I confirm that the information provided is accurate and complete to the best of my knowledge.
I understand that inaccurate health information may result in adverse reactions or complications during procedures.
I acknowledge that it is my responsibility to inform the technician of any changes in my health or medical conditions before any future appointments.
I consent to my personal data being securely stored and processed by the technician or salon in accordance with applicable privacy laws and the salon’s Privacy Policy.
I understand that this form will remain valid unless I report changes in my health, allergens, medications, or other relevant information.

I confirm that I have read, understood, and agree to all statements and terms.

Legal Confirmation Block. Electronic Signature Notice

By clicking "Submit" on the form, you acknowledge this submission as your legally binding electronic signature under the E-SIGN Act. Your name, email, and timestamp will be recorded to verify your consent.

Please click “Submit” only once and allow a few seconds for your responses to process. Thank you for your patience.

Client Information

Emergency Contact

Health Information

Previous Beauty Services

Client Consent and Acknowledgements

Required Legal Acknowledgements

Legal Confirmation Block. Electronic Signature Notice

Thank you!