Appointment Intake Form
Please fill this out before your appointment
Name
*
First Name
Last Name
Birthday
-
Month
-
Day
Year
Date / Fill this out if you'd like to receive a birthday discount
Email
*
example@example.com
Phone Number
*
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone
*
Please enter a valid phone number.
Do you have any known allergies (orally or topically)? If so, please list them here.
*
Are you sensitive to fragrances?
If you have any medical conditions that I need to be aware of before your service(s), please list them here. If you are sensitive to flashing/moving lights, or have epilepsy please list that here as well.
*
Do you have POTS or EDS?
Are you taking any antibiotics (oral or topical)?
Please list if you have any facial implants, piercings, dentures, or wear contacts
Do you have any medical devices or hardware I need to be aware of?
Massage
Please only fill this out if you booked a massage
Is this your first time receiving a massage?
Please Select
Yes
No
Are there any areas of the body you would like to avoid being massaged?
What kind of pressure do you prefer (only for barefoot massage)?
If receiving barefoot massage, have you had barefoot or ashiatsu massage before?
It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status. I understand that my personal health information will be collected. I understand that all information that I provide will be kept confidential unless required by law.
Facials / Face Massage
Please only fill this out if you booked a facial or face massage
Have you had a facial before? Was it recent?
Have you had any botox/fillers or chemicals peels in the last two weeks? If yes, please list the date below.
Do you get your face waxed? If so, please list the date of last wax:
Do you use any form of Vitamin A/Retinol or acne medications or have you been on Accutane? If so, please list the last date you took/used it.
Is your skin sensitive / reactive? Does it turn red or have a reaction when you apply products to it or get facials?
What type of skin do you have? (please check all that apply)
Normal
Combination
Oily
Acne
Dry
Sensitive
Mature/Aging
How would you rate your skin? (please check one)
Type option 1
Type option 2
Type option 3
Type option 4
What would you like to get from this facial or treatment?
What types of products do you normally use for your skin? What is your skincare routine like?
I understand that redness, sensitivity, peeling or other reactions may occur from a facial treatment. I further understand that estheticians are not qualified to diagnose, prescribe, or treat any disease or illness and that a facial should not be a replacement for medical treatment. I understand that facial results are not guaranteed and that for maximum results, more than one treatment may be required. The rate of improvement of my skin depends on my age, skin type, condition, degree of sun/environmental damage, pigmentation levels, or acne condition. I certify that I have read this entire consent form and I understand and agree to the information provided in this form. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive are voluntary and I release Mary K Curry of Sea Breeze Beauty from liability.
Photography Consent
Photos: I consent for photographs and/or video images to be taken of me by Sea Breeze Beauty. I understand the images may be used for marketing purposes (website, digital or social media). By consenting to photographs and/or video images I understand I will not be compensated from any party. Although photographs and/or video images will be used without identifying information such as name, I understand it is possible someone may recognize me. I further acknowledge that my participation is voluntary and agree that use of any photographs and/or video images confers no rights of ownership or royalties whatsoever. I hereby release Sea Breeze Beauty and its employees, and any third parties involved in the creation of or publication of educational or marketing materials, from liability for any claims by me or any third party in connection with my participation. By signing this form, I confirm understanding of this consent. If I wish to withdraw my consent in the future, I may do so via written request submitted to Sea Breeze Beauty or by completion of a new form.
*
Please Select
Yes
No
Please ONLY sign below if you agree to having photos / videos taken
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Submit
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