New Client Forms

1
Date* This field is required.
Date
Year
Month
Day
2
Client Name* This field is required.Please check all the boxes in the following slides to show you have read through our policies.
First Name
Last Name
3
Phone Number* This field is required.
Please enter a valid phone number.
4
Email
example@example.com
5
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
Medication History* This field is required.Please list all oral and topical medication you are currently taking, or recently taken in the past year (put "none" if n/a).
7
Do you have any types of allergy?* This field is required.Please put "none" if not applicable.
8
What is your skin type?* This field is required.
Dry
Oily
Combination
Normal
I don't know
9
What are your skin concerns?* This field is required.
Hyperpigmentation
Sun Damage
Oiliness
Dull/Dry/Dehydrated
Redness
Fine lines/Wrinkles
Enlarged Pores
Clogged Pores
Uneven skin tone/texture
Broken capillaries
Blackheads/Whiteheads
Don’t have any
Other
10
Do any of these contraindications relate to you?* This field is required.
Medications that exfoliate or thin the skin (Tretinoin, Renova, Tazorac, Retin-A, Differin, Avage, Accutane, etc)
Recent facial treatments, cosmetic surgeries, injectables (fillers & botox), laser resurfacing, chemical peels/dermabrasion
Tanning or waxing within 3-5 days prior
Pregnant or breastfeeding (must consult w/obstetrician prior)
Active Herpes simplex/prone to cold sores
Open sores or suspicious lesions
Severe rosacea or visible skin irritation
Sunburn or excessive sun exposure
Easily scarring/hyperpigmentation tendencies
Diabetes
High blood pressure
Heart disease
Deficient immune system
All forms of “active” cancer, chemo, or radiation treatment or history of skin cancer
Epilepsy/Seizure Disorder
Thyroid conditions
Systemic Lupus Erythematosus
Broken or inflamed skin
Use of photosensitizing medications that may cause light sensitivity
Metal implants (braces, etc)
Electrical implant (pacemaker, cochlear ear implant, etc)
None
Other
11
Do you have any tattoos or permanent makeup? * This field is required.If yes, please list where on your body and when they were done.
12
Do you smoke?* This field is required.If yes, please list how many times a day.
13
How many hours a day do you spend in the sun?* This field is required. .
14
Do you wear sunscreen daily?* This field is required.
YESNO
15
Tell me about your skin routine.* This field is required.Put "none" if not applicable.
Huge
Large
Normal
Small
Ok
Ok
16
Are you interested in any of the following services?
Eyelash Extensions
Eyelash Lift
Eyelash/Brow Tint
Waxing
Teeth Whitening
Body Sculpting
Microneedling
None
Dermaplaning
17
May I use your pictures and videos for marketing purposes?* This field is required.
YESNO
18
Reservation Policy* This field is required.Click all boxes to show you read and agree to the following:
A valid card is required to book, but will only be charged when cancellation/late fees occurs. ***If your card declines, you will not be allowed to book any more services until payment is made.
Please read and sign consent forms prior to your appointment.
Consultation will be conducted prior to your appointment so we can focus time & energy on your actual service.
19
Preparing for Your Appointment* This field is required.Click all boxes to show you read and agree to the following:
The area of your body that will be serviced MUST be clean prior to your appointment.
Do NOT drink caffeine prior to your appointment. Sleeping during your service is highly encouraged.
Phones must be switched to airplane mode. You may only use them if you want to enjoy your own audio with airpods/earbuds/headphones.
20
Payment Policy* This field is required.
HI tax of 4.712% will be included in your total.
Cards/Contactless Payment: There is an additional 3% processing fee.
Cash: Please bring exact change as I will not be able to give out change. You are welcome to round up and treat the difference as tip.
21
Cancellation, Reschedule, Late & No Show Policy* This field is required.We understand that life can unexpectedly happen. Please notify us if you need to make any changes no less than 24 hours before your appointment. Every client's business is valuable & important to us. When you cancel within that time frame, it doesn't give other potential clients enough time to book services. Therefore, business is lost for everyone. As compensation, you will be charged the following...
No-Shows, Cancellations, and Reschedules made less than 24 hours prior to appointments = 50% of the service.
Late more than 10 minutes = Your appointment will be forfeited and you will be charged the cancellation fee. (Reason being is we refuse to sacrifice quality due to rushing the service in order finish on time)
22
Client Signature* This field is required.By signing below, I understand and agree to all of the terms and conditions. I release Jess Beautiful LLC and my esthetician, Jessica Mae Tagalicud, from any and all claims and demands. I waive all liability of the business and esthetician if I am unintentionally exposed or harmed due to COVID-19, despite their great efforts in providing a safe and clean environment. I understand and accept responsibility in paying the cancellation, reschedule, late, or no show fees should I violate these policies.
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