Client Intake Form

Name*

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Phone Number*

Area CodePhone Number

Date of Birth *

Date

Occupation*

Today’s Date*

Date

How did you hear about us?*

Please indicated which services you are interested in.*

Please list ALL medications, supplements, or herbal remedies you currently take:*

Please list allergies or sensitivities:*

Please list Injuries or surgeries:*

Preferred Massage Pressure?*

Have you ever received professional skin care treatments - if yes please list when your last treatment was (not including with Aesthetics by Tay)?*

What are your specific concerns at this time regarding your skin/what you want to change? Please list your goals for the appointment.*

What do you consider your skin type?*

Do you wear spf every day? (This does not include spf in a moisturizer, or makeup)

YesNo

Do you struggle with following a routine/skip your skincare routine often?

Do you cleanse with hot water/take hot showers?

What would you say your worst skincare habit is? (If you have one! No judgement lol!) Ex: sleeping in makeup, picking at skin, etc.

Have you ever been treated for a skin condition? If yes, what condition?*

How did you treat the condition?

DermatologistAestheticianSelf Treated with products purchased from:

Drugstore (walmart, cvs, target)Department Store (belk, sephora, ulta)Other

Please check all that apply.*

Have you received any medical aesthetic treatments in the last 6 months? (botox, filler, etc.) If so, when?

Please upload a photo of all skincare you currently use.*

Browse Files

Do you have any underlying medical conditions your provider should be aware of?*

Do you have regular periods?*

YesNoOther

Are you going through menopause?*

YesNo

Do you smoke?*

YesNo

What is your stress level right now?*

LowAverageSomewhat StressedVery Stressed

How many hours of sleep do you get each night?*

Do you use a tanning bed?*

YesNo

How chatty do you prefer to be during your service? We want you to enjoy it completely!*

1 - I just want to relax!2 - some chat is okay!3- yes! I love chatting!

Please submit a front, left, and right facing photo of only your face in natural lighting with no makeup applied. *

Browse Files

Do you give permission for your photos to be shared on social media? (@taythe.estie instagram)

YesNo

By SUBMITTING THIS FORM, you agree to the following:
1) I give my permission to receive massage, facials, lash/brow and/or waxing services.
2) I understand that therapeutic massage is not a substitute for traditional medical
treatment or medications.
3) I understand that the therapist or esthetician does not diagnose illnesses or injuries, or prescribe medications.
4) I have clearance from my physician to receive facials and massage therapy.
5) I understand the risks associated with massage therapy, facials, and waxing include, but are not limited to:
• Superficial bruising or redness
• Short-term muscle soreness
• Exacerbation of undiscovered injury

I, therefore, release Aesthetics by Tay and the individual therapist or esthetician from all liability concerning these injuries that may occur during the session.
6) I understand the importance of informing my aesthetician of all medical
conditions and medications I am taking, and to let the aesthetician know
about any changes to these. I understand that there may be additional risks
based on my physical condition.
7) I understand that it is my responsibility to inform my therapist or esthetician of any discomfort I may feel during the session so he/she may adjust
accordingly.
8) I understand that I or the therapist may terminate the session at any
time.

POLICIES:

You must cancel/reschedule within 24 hours or you are charged 50% of your service fee. No exceptions.

No call - No shows are charged 100% of their service. No exceptions.

If you need to reschedule or cancel, please click the link in your confirmation text or email and it will prompt you to do so.

When you book an appointment, you check the box that states you agree to these policies.

Please do not bring guests to your appointment, unless approved otherwise. This includes children.

Location: 151 WENDOVER DRIVE, Kingsport TN 37663. Please arrive ON TIME, not late or early.

Please DO NOT wear makeup to your appointment as this takes away from the full time of your service.

Thank you!

Signature*

Client Form

Lifestyle