• New Client Intake

  • Client Information

  • Todays Date*
     - -
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Gender*

  • Health

  • Are you pregnant, or trying to become pregnant?*
  • Are you Breastfeeding?*
  • Do you have a pacemaker or valve replacement?*
  • Have you ever had fever blisters / cold cores / herpes?*
  • Do you...*
    • General Waiver 

    • Late Arrival

      I do not extend service times or issue refunds for late arrivals. Arriving more than 10 minutes late for your service will result in its cancellation and the application of a fee equal to 50% of the scheduled service price.

    • Cancellation Policy

      The time you schedule is reserved exclusively for you. When appointments are missed, or cancelled with insufficient notice, we're unable to fill the vacancy, causing substantial financial impact to the business. Should you need to cancel or reschedule your appointment with AKA Esthetics, we request 48 hours notice. Cancellations with less than 48 hours notice will result in a charge equal to 50% of the scheduled service(s).

    • - I have cited all conditions and circumstances regarding my health history, medications being taken, and any past reactions to products or medications in the "New Client Intake" form and will update my esthetician with any new information as soon as possible.

      - I understand that all services rendered to me are charged to me directly and that I am personally responsible for payment.

      - I have been clear of head lice at least one week prior to my appointment.

      - I will email to inform my esthetician of any complications or concerns I may have as soon as they occur.

      - I do not have active cold sores / herpes

       

    • Waxing Consent 

    • Some contraindications:

      Accutane, acne medications, uncontrolled diabetes, melanoma, open wounds, varicose veins, sunburn.
    • Have you ever been waxed before?
    • If yes, when was the last date you were waxed?
       - -
    • Have you used any of the following hair removal methods in the past six weeks?
    • Do you suffer from ingrown grown hairs?
    • Do you experience irritation from shaving?

    • - I understand that during the treatment, despite all precautionary measures, injury is possible and I will not hold the esthetician or business performing this service on me responsible in any way for any damages or issues that may arise as a result of having the waxing procedure performed on me.

      - I understand that waxing may result in bruising, ingrown hairs, and skin irritation, redness or inflammation.

      - I understand that the use of (AHA) alpha hydroxy or glycolic peels, other peels, Retin-a, Renova, scrubs, microdermabrasion, or tanned within 7 days prior to waxing is contraindicated and may cause the skin to lift or peel.

      - I am over 18 years of age or I have a parent/legal guardian with me and a consent form.

      - I understand some possible side effects include redness, swelling and pimples, these are temporary and usually fade after 72 hours.

      - For Brazilian or Bikini waxing I will notify my esthetician if I am on my menstrual cycle.

      - I have been off Accutane for at least 12 months.

      - I agree to adhere to all post waxing care including: no peels, tanning or wet room services, no swimming/saunas/hots/steam rooms or sex for at least 72 hours and all home care skin care protocols as recommended by my esthetician.

      - I will notify my esthetician of any complications or concerns I may have as soon as they occur.

       

    • Brow Tinting/Henna & Lamination Consent 

    • Some contraindications:

      Type of allergic reaction to any form of tint (including hair dye), eczema, infection, cuts or scabbing, sensitivity and redness in the brow area.

    • - I must adhere to all aftercare instructions

      - I understand an allergic reaction is possible

      - I understand that over the course of several weeks, the tint will gradually lighten and fade. Re-tinting will be required to keep the new color fresh. Recommended time between tints is 3-4 weeks.

      - I understand that, while every attempt will be made to provide me with my chosen color, everyone’s hair absorbs color differently and my final results may not be the color I initially wanted. Tinting will not thicken, lengthen or add additional hair but only tint present hair.

      - I understand that there may be some residual dark staining left on the skin following the tinting process of my brows. This will fade and go away within a short time.

      - I understand that there may be some residual dark staining left on the skin following the tinting process of my brows. This will fade and go away within a short time.

    • Signature 

    • By signing below, I release AKA Esthetics LLC and/or skin care professional from liability and assume full responsibility thereof. I have accurately answered the questions above, including all known allergies, prescription drugs, or products I am currently ingesting or using topically. I understand my esthetician will take every precaution to minimize or eliminate negative reactions as much as possible. In the event I may have additional questions or concerns regarding my treatment, I will consult the esthetician immediately. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written Page 1 of 2 disclosures. I certify that I have read, and fully understand, the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the esthetician, responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today. This agreement will remain in effect for this procedure and all future procedures conducted by AKA Esthetics. I have read and fully understand all information in this agreement. I am over 18 years of age and consent to the agreement and to treatment.

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