new client intake form

New client intake form

Medical history + consent
Name*

First NameLast Name
Todays date *

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com

Medications *

	WHEN	HOW LONG
ANTIBIOTICS
ACCUTANE
BENZOYL PEROXIDE
RETIN A
TAZORAC
DIFFERIN
AZELEX
AVITA
CELOCIN-T
E-MYCIN-T
COMPAXONE
CORTICOSTEROIDS
QUININE
ANDROSTENDIONE
TESTOSTERONE
PROGESTREONE
ESTROGEN
TYROID
GONADOTROPHIN
DANZOL
LITHIUM
ISONIAZID
STERIODS
MARIJIUANA
COCAINE/SPEED
OTHER
OTHER
OTHER
NONE

Do you use birth control pills, shot, IUD? If yes what kind?
Are you pregnant, nursing or trying to conceive*

pregnantnursingtrying to conceivenone of the above
I First Name* Last Name* consulted with my doctors before my appointment at Akme Aesthetics.

Medical History *

	YES	NO
HERPES SIMPLEX
ECZEMA
PSORIASIS
HEPATITIS
CANCER
STAPH INFECTION / MERSA
HIV/AIDS
TYROID PROBLEMS
HORMONE PROBLEMS
HYSTERECTOMY
OVARY (IES) REMOVED
PACEMAKER
HEMOPHILIA
LUPUS
ANEMIA
HIGH BLOOD PRESSURE
DIABETES
METAL PINS IN BODY

Your Primary Care Physician ( name + number) OR none *
Do you see a dermatologist?*

yesnoOther
Do you smoke?*

noyes
Do you use dryer sheets or fabric softener?*

YesNo
Have you ever had a reaction from a product you've used on your face? if so what. *
Are you allergic to anything?*

Please list your current home care routine / product names *

	YOUR PRODUCT NAMES HERE
CLEANSER
TONER
SERUMS
MOISTURIZER
SUNSCREEN
MASK
OTHER

Please select your primary skin concerns :*

	Please Select
Acne
Aging
Texture
Pigmentation
Pore Size
Scarring
Sunburn
Elasticity
Other

Do you consume the following?*

	0 times a week	1-3 times a week	5+ times a week
Fast food
Processed foods
Salty snacks
Milk / yogurt
Cheese
Whey/soy protein
Peanut butter / peanuts
Sushi
Sea food
Kelp / seaweed
Soy products

What treatments have you done to your skin in the last 90 days *

	Yes	No
Chemical peels
Microdermabrasion
Lasers
Facials
Facial waxing

client agreement form
Initial we must adjust your home care routine as needed to keep up the progress of clearing and or age management.
Initial I will not use other products that have not been approved by skincare professionals while I’m on their regimen.
Initial I will not will not change my routine given by my skincare professional without notifying / consulting with them.
Initial I will not run out of products while with my skin care professional I know when stopping use of products can stop the progress.
Initial I will not have another skin care treatment done by another skin professional while under going treatments with Akmē Aesthetics.
Initial I will inform my skin care professional but any medication/drugs I start to take while using their regimen.
Initial I will use my sunscreen every day whether or not I am going outside and I will reapply every two hours as needed.
Initial I will not get sunburned while undergoing treatment with my skincare professional.
Initial ( for women) I will inform my skin care professional if I get pregnant.
What are your skin goals you are trying to achieve this appointment / long term goals? *
What's you budget for routine / products? *
Have you seen skin specialist before? if so who and how was your experience? *
we like to take pictures at each appointment to track our progress , by filling the blank I hear by First Name* Last Name* give Akme Aesthetics permission to take pictures of my treatments / services.
Do you give permission to use your completed before/after on our social media?*

YesNo
Follow us on social to stay in the loop!

AKME Booking Policies.

When booking with Carly you must agree to these terms and conditions, if you do not agree to the terms & conditions you will be notified that your appointment will cancelled.
I First Name* Last Name* acknowledge that when I book with AKMĒ I am reasonable to up hold her booking policies. This includes her late cancelations policy & her no show policy.
Policies.

BOOKING POLICY

1. The price listed on the booking site is the session fee and will be charged in full at the time of your appointment. Not before your service date.

2. A valid debit or credit card must be on file in order to book and secure your appointment time. Valid debit or credit card must stay on file at all times until service is completed. If client wishes to secure another appointment, the card must remain on file.

3. The card on file is not charged upon booking an appointment. We only charge the card on file in the case of last minute cancellations or no-shows.

4. If the debit or credit card on file expires or is lost, a new valid debit or credit card must be updated in our booking system in order to secure appointments.

5. If the card on file declines when going to collect the late cancellation or no-show fee you will be reached out to via call, text and email to pay your remainding balance, in order to rebook all balances must be paid in order to rebook at akmē.

6. Failure to pay any remaining balance you will offically be blocked from our booking site, and your balance will be sent to our debt collector which will affect on your credit if not paid.
LATE POLICY

1.Tardiness is not tolerated.

2. If Client is 15 min or more late to appointment time, the appointment will classified as a no show, the card on file will be charged 100% of the appointment fee (see policy below). Client will then be required to reschedule their session. I work off an apointment only schedule you arriving late will put my whole day behind. We do not offer partial services in order to compensate for your tardiness. Please respect my time you decided to book for.

3. If you know you will be 15 min late, please send a notification either by phone or message so that we can reschedule you. You will be charged the 50% 24hr late cancellation fee (read 24hr policy below.)

Contact infomation : (405) 740 - 1020 or akmeaesthetics@gmail.com
LATE CANCELLATION POLICY

1. We have a 24hr late cancellation free of 50% of all services booked. Our booking site is designed to not allow you to cancel your services without contacting us first. We are typically booked out in advance, people waiting to come in. 24hr is to short of notice to guarantee that your stop will be filled.

2. Cancellations must be made no less than 24 hours in advance.
If a cancellation occurs within 24 hours of set appointment time, Client's card on file will be charged 50% of the listed appointment price.

3. If you choose to cancel and reschedule your appointment due to a Severe Weather Warning, including: Flash Flood Warning, Tornado Warning, Ice Storm or Winter Weather, or you do no feel safe driving due to valid inclement weather on the day of your appointment, you will not be charged a cancellation fee.

Contact infomation : (405) 740 - 1020 or akmeaesthetics@gmail.com
NO SHOW POLICY

1. If Client makes no attempt to contact us that they will not be present for the appointment, Client will be charged the 100% of the service amount and Client will no longer be able to book services at our salon.

Contact infomation : (405) 740 - 1020 or akmeaesthetics@gmail.com
PAYMENT

1. Client does not have to use the card on file to pay at checkout. At checkout, we accept debit/credit cards or exact cash for payment. We do not carry change.

2. Being unable or unwilling to pay for a service upon completion is considered Grand Larceny, a felony in the State of Oklahoma and is punishable with large fines and possible jail time.

3. Payment using counterfeit bills is a federal felony. This is obviously not tolerated and we will contact the police if this situation is presented at our place of business.

4. Do not book appointments if you are unsure that you will be able to afford the service cost.

5. If we attempt to charge your card for a missed appointment or late cancellation and the card on file is not valid, declined, or expired, Client will be expected to update their card on file immediately and pay for this charge within 24 hours. If the client refuses to update their card and pay the outstanding balance, they will banned from booking any further services from our salon. Your outstanging bill will be sent out to our debt collector, this will refect on your credit.
By booking your appointment time online OR pre-booking in person, you acknowledge you have read and agree to this cancellation policy.
Signature states you've read agreement carefully. *

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New client intake form

client agreement form

AKME Booking Policies.