Prismatique Maven Customer Multi-Services Registration, History & Pre-Consultation Form

Form date
Your Style. Our Expertise. Create A Vision Of Art.
Customer Multi - Services Registration, History & Pre-Consultation Form

To sign up for our client services, all customers must complete the registration information, history, and pre-consultation requirements listed below.

PRISMATIQUE MAVEN MESSAGE TO OUR NEW CLIENT/CUSTOMER
It is my honest wish to provide you with the best service possible. I want to provide your Waxing (Depilatory) Treatments, Facial care, Hair care, Hand & Foot Care, Nail Enhancements, Lash Care, Skin Treatment( Skin Resurfacing & Toning treatments, Permanent Makeup services), and I want to develop a long-lasting relationship with you. I'd like to understand more about you, your care needs, and your preferences in order to do so. Please take a moment to answer the following questions completely and accurately. Thank you, and I hope to create a "beautiful" friendship with you!

Customer Contact Information
Name*

First NameLast Name
E-mail*
example@example.com
Phone Number :*

(Cell)Phone Number
Phone Number

(Home)Phone Number
Phone Number

(Work) Phone Number
Phone Number

(Business) Phone Number
Address:*

Street Address

Street Address Line 2

CityParish

Postal / Zip Code
Occupation blanks
Birth Date:*

MonthDayYear
If Married , Anniversary Date :

MonthDayYear

Emergency Contact

Who should we call if you have a medical problem or an accident while being serviced (for example, seizures, blackouts, fainting, falling, etc.)?
Emergency Contact Name*

First NameLast Name
Relationship to you:
Emergency Contact Phone Number :*

(Cell)Phone Number
Emergency Contact Phone Number :

(Other)Phone Number

Hair Loss Details
Are you currently taking any medication that has side effects that can cause hair thinning and/or hair loss? If so,which one(s)?
Do you have now, or have had in the past, any problems with hair loss?

YesNo
Do you presently have any hairline breakage?

YesNo
Do you presently have any thinning areas?

YesNo
Do you presently have any bald spots?

YesNo

Micro-blading & Softap Permanent Makeup Details
Could you possibly provide photographs of eyebrows looks that you've been inspired by?

Browse Files

Cancelof
It's time to share your selfie! Could you please send me a picture of your eyes & full view of your face? Please make sure the photo you provide is a clear, FILTER-FREE image of yourself. Instructions on how to take the ideal selfie may be found in the image below.
Here the images of your face and eyes will be uploaded. If I am unable to use the photos you send, I will contact you for a new one.

Face & Eyes Inspo Files

Cancelof
Please read and complete each of the following links before your appointment.

https://form.jotform.com/prismatique.maven/-TermsAndConditions

https://form.jotform.com/prismatique.maven/covid-19-salon-services-consent-for

Waxing Details
Please read and complete each of the following links before your appointment.

https://form.jotform.com/prismatique.maven/-TermsAndConditions

https://form.jotform.com/prismatique.maven/covid-19-salon-services-consent-for

CLIENT RELEASE STATEMENT I have read, understand and completed this questionnaire truthfully. I understand that withholding information or providing misinformation may result in undesired results and/or irritation to the skin or nails from services received. The services I receive here are voluntary, and I release this business and/or cosmetologist, esthetician , nail technician from liability and assume full responsibility thereof..
PHOTOGRAPHY & IMAGE RELEASE STATEMENT For the purposes of documentation, I, the customer herein subscribed, voluntarily consent to "before and after" images. Prismatique Maven and its affiliates have the total right and unfettered authorization to take, use, and show photographic photos of me in any kind of media, and I, the client herein signed, grant them this license. For art, advertising, media release news articles, marketing, publicity, archive, or any other legitimate purpose through any type of media (print, digital, electronic, broadcast, or otherwise) at any place I relinquish any right to royalties or other compensation as a result of or in connection with the use of photographic photos of myself. I agree to keep Prismatique Maven and its affiliates blameless from any liability arising from the capturing or use of the photographs.
Signature*

Clear
Once you've finished reading, initialing / signing, and submitting your Appointment, Deposit, Initial Customer Registration, History, and Pre-Consultation forms,Instructions, waivers, and releases are all required prior to the appointment.

We'll see you at your scheduled time.

Thank you very much!
Should be Empty:

	Brand Of Product Used	How often/when do you do it on a daily/weekly basis?
Body Soap:
Bread Oil :
Brow Products:
Cleanser:
Day Moisturizer:
Exfoliate (chemical) :
Exfoliate (physical) :
Eye Cream:
Eye Makeup Remover:
Eye Primer:
Eye Serum:
Eye Shadow:
Eye Treatment:
Eyelash Fortifier/ Conditioner:
Eyeliner:
Facial Cleanser:
Facial Mask:
Facial Primer:
Facial Serums :
Facial Shaving Cream :
Facial Sunscreen SPF:
Facial Toner:
Hair, Skin and Nail Supplements:
Mascara:
Mask:
Moisturizer:
Night Moisturizer:
Toner:

	Brand Of Product Used	How often/when do you do it on a daily/weekly basis?
Body Moisturizer
Cuticle Oil
Hand Cream:
Exfoliate (physical) :
Hair, Skin and Nail Supplements:
Body Butter

Customer Multi - Services Registration, History & Pre-Consultation Form

PRISMATIQUE MAVEN MESSAGE TO OUR NEW CLIENT/CUSTOMER

Customer Contact Information

Emergency Contact

Medical History

Medical Treatments / Surgeries / Supplement Info

ALLERGIES OR SENSITIVITES

Vitamin & Nutritional Supplements intake

LIFESTYLE EVALUATION

SKIN INFORMATION & SKIN CARE DETAILS

PERSONAL SKIN CARE

Questions for both Eyelash Extensions & Facial Details

Eyelash Extensions Details

Hair Loss Details

Facial Details & EPI-Leveling Consent

Manicure & Pedicure Details

Manicure Details

Pedicure Details

Nail Enhancements Details

Micro-blading & Softap Permanent Makeup Details

Waxing Details

Aromatic Therapy Details