Service Intake Form

Skin Deep Day Spa, LLC

1216 Wildwood, Suite C, Jackson, MI 49202

517.990.9088 - skindeepspajackson.com
SERVICE INTAKE FORM

General Information - Health History - Skin Care/Waxing - Massage
Please complete this form thoroughly and answer the questions honestly.
General Information
Name *

First Name Last Name
Today's Date *

Month Day Year
Date
Date of Birth *

Month Day Year
Date
Phone Number *

Area Code Phone Number
Email
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Emergency Contact Name *
Emergency Contact's Phone Number *

Area Code Phone Number
What is your occupation?
How did you hear about us? *
Referral Name *
If you heard about us some other way, please explain *

SERVICE INTAKE FORM

General Information - Health History - Skin Care/Waxing - Massage
In signing this form I acknowledge and testify as to the following;

All information I have given both written &/or verbally, is true to the best of my knowledge and it is my sole responsibility to inform &/or update Skin Deep Day Spa LLC as to any changes in my health status &/or personal information.

I, the client, as well as the attending practitioner have the right to stop or refuse any treatment or service at any time.

I understand, Skin Deep Day Spa LLC’s practitioners do not diagnose any illness or medical condition, nor will Skin Deep Day Spa LLC’s practitioners work outside guidelines as defined by the State of Michigan in Scope of Practice for the type of service offered at any time for any reason.

I hereby release, hold harmless, waive, discharge, and covenant not to sue Skin Deep Day Spa, LLC, its directors, oﬃcers, employees, volunteers, and agents with respect to any liability for any injury, loss, and/or damage (including, but not limited to, illness or death) that I may sustain related to services &/or treatments rendered. I further hereby knowingly consent to receive treatment from Skin Deep Day Spa, LLC.
Date *

Month Day Year
Date
Signature *

Clear
Parental Consent Signature (required for clients under the age of 18)

Clear
Should be Empty:

SERVICE INTAKE FORM