GRS Client Intake

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.

Date

1) Have you been under the care of a physician, dermatologist or any other medical professional within the past year?

YESNO

Please Explain:

2) Have you undergone any recent surgeries or plastic surgery/aggressive medical treatments in the past year?

YESNO

Please Explain:

3) Are you currently taking and medications/herbal supplements/vitamins orally or topically? If YES, please list below. ( If you are currently using Retinol or Antibiotics please list frequency of use.)

4) Please list any known Allergies or any ingredients, scents (aromatherapy) that cause you discomfort.

5) Please list any pre- existing or current medical conditions that you have been diagnosed with.

6) Please list any current injuries that cause you discomfort?

7) Are you currently pregnant or trying to become pregnant or nursing?

8) Our therapeutic treatments include scalp massage, foot/leg and some ear massage reflexology. Please indicate if you feel uncomfortable with any of the above to ensure you have the most pleasant experience. Massage pressure preference?

9) We’re so happy you choose Green Revolution Studio! We’d love to know who referred you or how you heard about us!

10) We want to make sure you have a wonderful treatment experience with us here at GRS. Is there anything else you wish to share with us?

11) Do you prefer relaxation music paying during your treatment?

12) Are you open to a scalp massage treatment during your service?

About your Therapeutic Treatment at Green Revolution Studio

The customized treatments we provide include some peels and masks that are derived from natural sources yet still feel active on the skin. Our peels may contain lactic acid, AHA’s/BHA’s and Salicylic acids that may cause some peeling and irritation.During the treatment, extractions (the removal of white heads and black head congestion) may be performed which can occasionally bruise or irritate the skin if the skin is sensitized by oral or topical prescription creams or medications.Please inform us of any known pre existing medical conditions, allergies, topical and oral medication use such as-Retinol, Accutane, Antibiotics (or any chemically charged anti-aging or acne creams that may contraindicate facial or waxing treatments.)Bringing the above information to your skin therapist’s knowledge is extremely important to ensuring your comfort and safety.All client information listed and discussed during your treatment session with your skin therapist is kept confidential to honor your privacy.

Treatment Consent Agreement

I am permiting the liscenced esthetician working with me at Green Revolution Studio to perform waxing and facial services of my choice on me. I have read and fully understood this form carefully and answered all questions to the best of my knowledge. I clearly understand that the information provided for me about the services rendered.I agree to inform the therapist working with me at Green Revolution Skin Studio of any pre existing or current medical conditions and allergies to ensure my health and safety as well as the health and safety of my therapist.

Sacred Time Cancellation & Rescheduling Policy:

•24-Hour Notice Required

Any cancellations or reschedules made within 24 hours of your appointment will incur a $50 fee.

•First-Time Courtesy

If it’s your first time needing to reschedule under 24 hours, we’ll honor your $50 fee as a credit toward your rescheduled service — one time only.

•No-Call / No-Show

Appointments missed without notice will be charged 100% of the serviceand will not be eligible for rebooking.

•Mindful Scheduling

Frequent cancellations or rescheduling can deeply impact our small business. Each appointment holds a dedicated two-hour block, and with limited availability, it’s difficult to fill these last-minute. We kindly ask that you be mindful when booking and only reserve time you’re fully committed to keeping.

We’ve done our best to create a policy that is rooted in respect and understanding. These changes are intended to support not only our ability to serve you with presence and intention, but to preserve the longevity and health of our small business.

Thank you for being a part of our community and for continuing to choose us as a place for your skin, mind, and soul to be nurtured.

What if I'm running late?
To respect all clients' schedules, late arrivals will only receive the remaining appointment time. If you're running late, please notify us by messaging us through the Square booking app or text 301.656.2000.

Signature

Name

First NameLast Name

GRS NEW CLIENT INTAKE