Service Intake Form

Skin Deep Day Spa, LLC

1212 Wildwood, Suite A & B, 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*

MonthDay Year
Date
Date of Birth*

MonthDay 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 or to COVID-19. I further hereby knowingly consent to receive treatment from Skin Deep Day Spa, LLC.

Note: All prices are subject to change without prior notice. Skin Deep Day Spa LLC.

I understand the following cancellation policy: Cancellation of appointments with less than a 24-hour notice are charged a cancellation fee of 50% of the missed service. Spa Packages and Spa Parties will need to give a 48 hour notice. The credit card on file is charged a fee of 100% of the missed service and will be required to place a nonrefundable deposit to schedule future appointments. Two no shows in a 12 month period will result in termination of our practice.
Date*

MonthDay Year
Date
Signature*

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

Clear

PHOTO RELEASE FORM
I, First Name Last Name authorize Skin Deep Day Spa to take photographs of my face/treatment area. With the sole intent of encouragement to others that may be considering the same or similar procedures, your photos may be considered of such a good quality that we may choose them for the spa photo album, or social media advertisement to educate future clients, such as Instagram and/or Facebook. At no time will any personal information or name be given. These photographs may be used for client referrals and/or educational purposes.
Skin Deep Day Spa may use my photo for educational and/or promotional purposes.

YESNO
I authorize pictures to be taken for before and after visual result for the esthetician and client, but I prefer not to have them used for advertising and/or promotional purposes.

YESNO
Client Signature

Clear
Should be Empty:

SERVICE INTAKE FORM

General Information

SERVICE INTAKE FORM

Health History

SERVICE INTAKE FORM

Skin Care/Waxing

SERVICE INTAKE FORM

Massage

SERVICE INTAKE FORM

PHOTO RELEASE FORM