Haute & Bodied Beauty Lounge, LLC Client Intake Form

CLIENT INTAKE FORM
How did you hear about us?*

Friend/RelativeWeb SearchFlyer/Social MediaGrouponOther
Name*

First NameLast Name
Gender*
If female, are you pregnant?
Date of Birth*

MonthDayYear
Date
Email Address*
example@example.com
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
What service are you booking for or interested in? *
High Blood Pressure?*
List any known allergies and/or medical conditions.
List any previous surgeries.
Any major concerns for this visit? *
If yes, please explain.
Photo Consent: I consent to have photos and videos taken during my treatment for Haute & Bodied Beauty Lounge's social media use and/or for record of my treatment. *
Release: I recognize that there are certain inherent risks associated with any treatment and I assume full responsibility for personal injury to myself. In exchange for such treatment, I hereby fully release and forever discharge Haute & Bodied Beauty Lounge, LLC and it's technicians from any and all damages, costs, expenses, liabilities, cause of action, claims and demands, of whatever character, in law or in equity, whether known or unknown, direct or indirect, asserted or unasserted, and whether or not on account of myself, Haute & Bodied Beauty Lounge, LLC or other third parties, or in any way arising out of the above described treatment I have requested Haute & Bodied Beauty Lounge, LLC or it's technicians to perform. It is the intention of the parties that this agreement binds all parties whose claims may arise out of or relate to the treatment or services provided by Haute & Bodied Beauty Lounge, LLC including any spouse or heirs of the client/patient and any children, whether born or unborn. Any legal or equitable claim that may arise from participation in the treatment shall be resolved under Texas state law.

I agree to indemnify, hold harmless and defend Haute & Bodied Beauty Lounge, LLC and/or it's technicians against all claims, cause of action, damages, judgments, costs or expense, including attorneys' fees and other litigation costs, which may in any way arise from the any treatment I have requested Haute & Bodied Beauty Lounge, LLC to perform.
Client Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

CLIENT INTAKE FORM