BEAUTY BY BOWERS

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
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
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:
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?
If yes, how many weeks?
Are you currently using Accutane or Retin A
Are you currently seeing a chiropractor, physical therapist, or physician for an ongoing issue?
Have you ever received a facial before?
When was your last session?
Have you received massage therapy before?
If yes, when was your last session?
Desired pressure
Are you currently seeing a dermatologist?
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?
If Yes, What type of makeup do you typically wear?
Have you received a wax service before?
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.

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 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.
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
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
Should be Empty:

Client Survey

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