Red Hot Beauty Lounge: New Client Intake Form NEW

RED HOT BEAUTY LOUNGE

414-544-3244 | www.redhotbeautylounge.com | redhotbeauty@yahoo.com

Name *

First Name Last Name

Phone Number *

Area Code Phone Number

Your Birthday *

Date

Email *

May we add you to our email list?

Mailing Address

Street Address

Street Address Line 2

City State

Zip Code

How do you prefer for Red Hot Beauty Lounge to contact you? *

Emergency Contact *

First Name Last Name

Emergency Contact Phone Number *

Area Code Phone Number

How did you hear about me? *

Facebook Instagram Google Search Referral (type name below)

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Allergies?

How often do you receive facial/ skincare services? *

When was your last facial/ skincare service? *

What are your top priorities to be addressed at your appointment? *

Fine lines/ wrinkles Acne Scarring Dark spots Hyper-pigmentation/ Hypo-pigmentation Anti-aging

What are your current issues & how are they affecting you? *

Please list all medications:

Please list current daytime and night-time skincare routine: *

Do you have any special needs I should prepare for?

Do you allow your esthetician to take pictures during your visit for social media?

Yes No

Do you have an implanted electronic device in your body (like a Pacemaker, ICD, or medicine pump)? *

Are you currently pregnant? *

Which prescription medications are you currently taking? *

I am NOT taking any prescription medications. I just take Aspirin for my heart. I take a blood thinner medication.

Medical History: If you have experienced any of the symptoms that is marked with an asterisk (*), please call Ashley to discuss your medical history before booking an appointment; this is to ensure your safety and well-being.

Medical History *

Current

Past

Never

Pregnancy*

Blood Clots*

Pacemaker*

Congestive Heart Failure*

Unexplained Calf Pain*

Varicose Veins*

Stroke or Heart Attack*

Cancer*

Car Accident*

High Blood Pressure

Low Blood Pressure

Epilepsy / Seizures

Chronic Headaches / Migraines

Chronic Dizziness / Ringing Ears

Digestive Disease (IBS, Crohns, etc)

Chronic Constipation

Chronic Diarrhea

Kidney Disease / Chronic UTI's

Arthritis (rheumatoid, osteoarthritis)

Scoliosis / Kyphosis / Lordosis

Osteoporosis

Degenerative Spine / Disk

Broken Bone

Allergies that Require an Epi-Pen

Autoimmune Condition (Celiac, Hashimotos, Lupus, Graves, etc)

Diabetes / Insulin Resistance

Endocrine / Thyroid Condition

Chronic Depression

Chronic Anxiety

Chronic Swelling

Sensitive to Touch / Pressure

Easy Bruising

Shortness of Breath / Asthma

Chronic Muscle / Joint Stiffness

Chronic Muscle / Joint Pain

Chronic Pain

Chronic Numbness / Tingling

Neurological Condition (ALS, Parkinsons, etc)

Chronic Skin Rash

Highly Sensitive to Certain Smells or Fragrances

Fibromyalgia

Multiple Sclerosis

Memory Loss / Confusion

Cancellation Policies

No Call/No Show: If you no call/ no show your card on file will be charged 100% of your service

Late Arrival: If you are 15 minutes late to any appointment 30 minutes or less your appoinment will be cancelled and charged 50%.

Rescheduling: Failure to cancel or reschedule your appointment at least 24 hours in advance will result in a charge of 50% charge of the scheduled appointment. All appointments will required to have a credit card on file. Your card will not be charged unless you cancel less then 24 hours or no show.

Sick Policy: Please always reschedule if you or your immediate family is ill or has been in the last 48 hours. We work very closely with clients and take every precaution to keep our spa safe and sanitary.

Spa Etiquette: Please keep voices down upon entering the building as other services may be in session. Turn your cell phone off or put it on silent to ensure your service or another service is not interrupted. If you need to make any calls please do so outside

Sickness Policy

Please reschedule your appointment as soon as you are aware of an infectious or contagious condition.

If you arrive for your appointment with symptoms of an illness, you must reschedule your appointment.

If you experience any of the following symptoms, you must reschedule:

Fever or Chills
Vomiting or Diarrhea
Runny Nose
Sore Throat or Cough
You are currently taking an antibiotic.
You have a skin infection like ringworm or athletes foot.
You or someone in your direct care has a cold, sinus infection, or flu bug.
You or someone in your direct care has been diagnosed with influenza (the flu).

Even if you are cancelling your appointment within the 24-hour notice period, the cancellation fee may be waived; the onset of symptoms doesn't always have great timing, right?

Informed Consent

By typing my first name, last name, and providing my e-signature below, I am indicating the following:

1. I have read the New Client Intake Form for Red Hot Beauty Lounge in its entirety.

2. I fully understand all questions and information provided in the New Client Intake Form for Red Hot Beauty Lounge.

3. I have completed the New Client Intake Form for Red Hot Beauty Lounge accurately and to the best of my knowledge.

4. I have read and I understand the expectations and policies for Red Hot Beauty Lounge and I agree to the terms and conditions outlined.

Type Full Name: *

First Name Last Name

Signature *

Today's Date *

Month Day Year

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