BEAUTY BY BOWERS

BEAUTY BY BOWERS

Day Spa
Client Survey

Please fill out this form completely, sign and submit before your appointment.
Name*

First NameLast Name
Middle Int.*
Address*

Address

Street Address Line 2

CityState

Zip
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Cell Phone*

Area CodePhone Number
Date of Birth*

MonthDayYear
Date
E mail*
example@example.com
Emergency Contact *
Name & Number
How did you hear about us?*
Your Profession
Preferred Method of contact for appointment confirmations (Call, Text and/or Email)*
Please check all that apply and explain on lines listed below:
Do you have any of the following:*

AllergiesOsteoporosisFibromyalgiaRheumatoid ArthritisBroken/Fractured boneHerpes/ShinglesCarpal TunnelSpasms/CrampsMuscular DystrophyDisc ProblemsNeck ProblemsTMJJaw PainPsoriasisNumbness/Tingling/Sprains/StrainsParkinson's diseaseRecent SurgeriesVaricose VeinsHypothyroidHyperthyroidWarts (Hands &/or Feet)LymphedemaFever Blisters/Cold SoresRosaceaHigh Blood PressureLow Blood PressureNONE OF THE ABOVE
Explanation(s) of any conditions checked above:
List current medications*
If none type N/A
Do you have any allergies (Food, Environmental or Product), please list specifically (If NONE put N/A):*
Are you currently pregnant?*

YesNo
If yes, how many weeks?
Are you currently using Accutane or Retin A*

YesNo
Are you currently seeing a chiropractor, physical therapist, or physician for an ongoing issue?*

YesNo
Have you ever received a facial before?*
When was your last session?
Have you received massage therapy before?*

YesNo
If yes, when was your last session?
Desired pressure

LightFirmDeep
Are you currently seeing a dermatologist?*

YesNo
If yes, when was your last session and reason for being treated?
Do you wear makeup?*
If so, what brands?
If so, how often do you wear makeup?*

4-6 times/week2-3 times/week1/weeknoneEverydayNEVER
If Yes, What type of makeup do you typically wear?*

powderfoundationeye shadoweyelinerlipsticklipglossSupplemental lashesNONE
Have you received a wax service before?*

YesNo
If Yes, did you have any irritation or reaction to the waxing service? What was it?*
What facial cleansing and moisturizing products and makeup do you currently use (brand and name)?*
Service Agreement and Liability Release Waiver

Please check next to each statement. Then, sign and date the form.
Client Survey

Please fill out this form completely and submit before your appointment.
Please check next to each statement to acknowledge your understanding. Sign and submit the completed form below.*

Modesty draping will be utilized. Body parts addressed will be only those that directly pertain to the service.You understand that the services you receive from Beauty by Bowers Day Spa are provided for the basic purposes of beauty, skin care education, relaxation, and relief of muscular tension.You understand that it is your responsibility to inform Beauty by Bowers and your esthetician/therapist of any pre-existing conditions, limitations, or specific sensitivities and to inform your esthetician/therapist immediately if you feel any discomfort during your spa services.You understand that because spa services should not be performed undercertain medical conditions, you affirm that you have stated all of your knownmedical conditions and answered all questions honestly. You agree to keep theesthetician/therapist updated as to any changes in your medical profile andunderstand that there shall be no liability on the esthetician’s/therapist’spart or Beauty by Bowers Day Spa should you fail to do so.You understand that should you have a medical condition; you affirm thatyou have been cleared by your doctor/presiding medical care giver to receive sparelated services; also, that any spa service that you request is cleared byyour doctor/presiding medical care giver.You understand that any illicit or sexually suggestive remarks oradvances made by you will result in immediate termination of the session, andyou will be liable for payment of the scheduled appointment.You understand that cancelled appointments without a 12 hour notice or missed appointments will be charged at 50% of the scheduled session cost.Beauty by Bowers is committed to providing the utmost professional service; if you are dissatisfied at any time, promptly notify a member of the Beauty by Bowers management team. Complaints not received within 48 hours after the initial rendering of services may not be honored.You understand that we will not service any person under the age of 18 without a liability release waiver signed on their behalf by their legal parent, legal guardian, or legal custodian.YOU UNDERSTAND AND VOLUNTARILY ACCEPT ANY RISKS ASSOCIATED WITH YOUR SPA SERVICES AND UNDERSTAND, BEAUTY BY BOWERS DAY SPA, LLC., ITS EMPLOYEES, OR AFFILIATES WILL NOT BE HELD LIABLE FOR ANY INJURY OR DAMAGE, INCLUDING, WITHOUTLIMITATION TO: PERSONAL, BODILY, OR MENTAL INJURY, ECONOMIC LOSS, OR ANY OTHERDAMAGE TO YOU, YOUR SPOUSE, GUEST, UNBORN CHILD, OR OTHERS RESULTING FROM BEAUTY BY BOWERS OR ANYONE ACTING ON BEHALF OF BEAUTY BY BOWERS.You have read and understand that payment is due when services are rendered. You have read and understand the Beauty by Bowers payment policies.Beauty by Bowers Day Spa reserves the right to refuse services at anytime, for any reason.
By signing and dating below, you acknowledge that you have read, understand, and agree to the entirety of this Liability Release Waiver.
Client's Printed Name*
Client's Signature*

Clear
Date*

MonthDayYear
Date
Print name of minor (under the age of 18)
Print name of Legal Parent/Guardian/Custodian*
If Client. 18 or older type N/A
Date*

MonthDayYear
Date
Legal Parent/Guardian/Custodian Signature*

Clear
Should be Empty: