New Client Consultation Form
Fifth & Mae Salon
Date
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Month
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Day
Year
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Name
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First Name
Last Name
Date of Birth
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Phone Number
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Area Code
Phone Number
E-mail
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How did you hear about me?
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Website / Online Search
Yelp
Instagram
Referral
Other
If Referral, please list name
If Other, please let me know
Your Skin
What are your skin care goals?
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What are your skin care challenges?
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Wrinkles / Fine Lines
Hyperpigmentation / Sun Damage
Acne / Acne Scarring
Redness / Rosacea
Aging
Melasma
Sensitivity
Other
Please feel free to go into more detail
Have you ever had a facial or skin treatment before?
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Yes
No
If Yes, when?
What Skin Care Products do you currently use?
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Cleanser / Face Wash
Bar Soap
Face Scrub / Exfoliants
Toner
Serums
Moisturizer
Sunscreen
Eye Product(s)
Lip Product(s)
If you are seeking corrective treatments please detail the SPECIFIC products
(BRAND & PRODUCT TYPE/NAME)
you are currently using so I can best answer any questions on ingredients and help you meet your skin care goals.
Cleanser / Face Wash
Bar Soap
Face Scrub / Exfoliants
Toner
Serums
Moisturizer(s)
Sunscreen
Eye Product(s)
Lip Product(s)
Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?
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Yes, currently using
Yes, but not within the last 30 days
Yes, but not within the last 6 months
No
Not sure
Please specify which product or type, if you answered 'Yes, currently using' to above.
Have you received any of these hair removal services in the last 30 days?
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Waxing
Sugaring
Threading
Electrolysis / Laser
Depliatory Cream
Shaving
None
If checked, please note last time.
Have you ever received chemical peels, laser services, or microdermabrasion treatments?
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Yes, within the last month
Yes, within the last 2-3 months
No
Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks?
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Yes
No
Your Health
Have you experienced any of these health conditions in the past or present?
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Hormone Imbalance
Cancer / Systemic Disease
High Blood Pressure
Diabetes
Heart problem
Arthritis
Auto-Immune Disorders
Asthma
Epilepsy / Seizure Disorder
Fever Blisters
Herpes
Frequent Cold Sores
HIV/AIDS
Lupus
Depression/Anxiety
Hepatitis
Headaches / Migraines
Other
None
If you checked yes to any of these please provide further information. If not mark N/A
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Do you?
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Wear contact lenses
Have a pacemaker
Have metal implants
Have body piercings
No, not Applicable
Do you take any of the following dietary / health supplements?
Multivitamin
Vitamin C
Vitamin D/D3
Zinc
Omega 3 / Fish Oil
B Complex / B12
Garlic
Calcium
Folic Acid
Melatonin
Coenzyme Q10
Biotin
Other
If other, please list
Any known allergies?
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Aspirin
Tree Nuts
Latex
Dairy
Fruits
Vegetables
Shellfish
Iodine
Fragrances / Essential Oils
Other
None
If Other, please specify
Have you used or been prescribed any medications (topical or oral) for acne / acne control?
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Yes
No
If yes, please specify what and date last used
Are you a smoker?
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Yes
No
Social
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)
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Yes
No
Please rate your stress level
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Low
Medium
High
Do you consent to having progress/ before & after photos taken & posted to social media?
Yes
No
Would you prefer a relaxing “quiet” session or to be informed along the way?
Quiet session
Informed
Are you taking birth control?
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Yes
No
N/A
If yes, what kind
Are you pregnant or trying to become pregnant?
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Yes
No
Recently had a baby and am breastfeeding
N/A
Any menopause issues?
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Yes
No
N/A
If yes, please specify
Are you undergoing any hormone replacement therapy?
Yes
No
If yes, please specify
Please read and sign where indicated.By submitting this form, you are agreeing that:1) I give Fifth and Mae Salon my permission to perform the treatment(s). 2) If I am not over the age of 18 I agree that a parent or guardian must sign and consent to treatment. 3) I understand that this service is not a substitute for traditional medical treatment or medications.4) I understand that the esthetician does not diagnose illnesses or injuries, or prescribe medications.5) If I am under the care of a physician, I have clearance from my physician to receive facial treatments.6) Although it is impossible to list every potential risk associated with treatments, I understand the risks include, but are not limited to:* Superficial temporary redness or sensitivity* Allergic/histamine reaction to products used* Exacerbation of undiscovered/undisclosed injury or medical conditionTherefore, I release Fifth and Mae Salonand my esthetician from all liability concerning these and other possible risks associated with any treatment.7) I understand the importance of informing my esthetician of all medical conditions and medications I am taking, and to let my esthetician know about and changes concerning these. I understand there mey be additional risks based on my physical condition/health.8) I agree to adhere to all post-care recommendations, including: no peels, tanning, or wet room services; no swimming/spas hot tubs for 72 hours after waxing; and all home skin care protocols as recommended by my service provider.9) I recognize there are no guaranteed results and that all independent results are dependent on age, skin condition, and lifestyle. I understand there is the possibility I may require further treatments to obtain the desired results, at an additional cost.10) I understand how important it is to follow all post-treatment instructions given to me by the esthetician. In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult the esthetician immediately.11) I understand it is my responsibility to inform my esthetician of any discomfort I may feel during the treatment session, so they may adjust accordingly.12) I have given an accurate account of my medical history, including all known allergies, prescription drugs, or products I am currently ingesting or using topically.13) I understand that I, or the esthetician, may terminate the session at any time and for any reason.In consideration of my participation in Spa services (massage, waxing, , facials, body treatments,etc.) at Fifth and Mae Salon , I hereby release, discharge and covenant not to sue Fifth and Mae Salon, including their respective directors, officers, employees, agents, representatives, insurers, clients, successors, assigns, and any property owners, (“Released Parties”) and further release from liability of negligence. Spa Services are not medical, and should not be considered, a substitute or diagnosis or treatment by a licensed medical professional. Guests should consult a physician requiring participation in the Spa Services and shall update Released Parties with any changes in health and Released Parties shall not be liable for failure to do so.I understand participation in the Spa Services carries certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries; my participation in the Spa Services is voluntary . CANCELLATION POLICY: Out of respect for my time and other guests’ time, it is required to add a card on file for when you book spa appointments. I ask that you please reschedule or cancel at least 24 hours before the beginning of your appointment. In the event that you need to cancel or reschedule an appointment with less than 24 hours notice, No show, or are more than 15 mins late to your appointment with no communication, the card on file will be charged a cancellation fee of 50 percent of the price of your scheduled appointment(s). If you need to cancel or reschedule, you can do so by text or call (470.921.9346). All services are non-refundable. If you have any questions or concerns about your service(s), I am happy to offer a complimentary consultation and adjustment if needed within the first 7 days.
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I HAVE READ AND UNDERSTAND THIS WAIVER.
Signature
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