Client Intake & Consent Form

Client Intake & Consent Form
Welcome to Petal & Bloom Spa! Please take a moment to complete this form before your service.

Fill out General Information. Then, only complete the section(s) related to the specific service(s) you're receiving today.

If receiving multiple services, please complete all relevant sections.

Be sure to review and sign the Final Consent section at the end.

Your comfort, safety, and satisfaction are our top priorities. Thank you!
GENERAL INFORMATION (Required for all clients)
Full Name
Date of Birth

MonthDayYear
Date
Email
example@example.com
Phone Number
Emergency Contact Name
Emergency Contact Phone
Are you currently pregnant or breastfeeding?

YN
Are you under the care of a Dermatologist?

YN
If you answer yes please explain
Do you have any known allergies (e.g., latex, lidocaine, adhesives)?

YN
If you answer yes please explain
FACIALS
Are you currently using Retin-A, Accutane, or other prescription exfoliants?

YN
Have you had a chemical peel, laser, or microdermabrasion in the past 2 weeks?

YN
Are you experiencing sunburn or recent overexposure to the sun?

YN
Do you have any active infections, cold sores, or open wounds?

YN
(For micro-current treatments) Do you have dental implants, braces, or metal in your jaw or mouth? If yes, have you had any sensitivity with facial electrical devices?

YN
Are you using any exfoliating agents (e.g., AHA/BHA, Retinol)?

YN
If you answer yes please explain
Do you have eczema, psoriasis, or skin issues in the treatment area?

YN
Have you had Botox or filler in the area in the past 4 weeks?

YN
LITTLE BLOOM FACIAL (To be filled out by primary caregiver 18 years or older)
I understand that this is a treatment designed for 12 year olds and younger for relaxation and mild skincare only.
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I confirm my child has no known allergies or sensitivities to skincare products, lotions, or essential oils.
If yes, please explain
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I give permission for my child to receive this facial and understand that results may vary.
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I release Petal & Bloom Spa from any liability related to unforeseen skin reactions.
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I understand photos may be taken for marketing purposes on social media.
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Print Name

First NameLast Name
Date

MonthDayYear
Date
BACK FACIALS
Are you currently using any topical acne medications or acids on your back?

YN
Do you have any irritation, acne, or broken skin on your back?

YN
BROW LAMINATION/LASH LIFTS
Do you have sensitive skin or a reaction to perming chemicals?

YN
If you answer yes please explain
Have you had any recent eye surgeries or infections?

YN
If you answer yes please explain
Have your brows/lashes been chemically treated within 6-8 weeks?

YN
WAXING
Have you exfoliated or tanned in the last 48 hours?

YN
Do you have skin sensitivities or a history of lifting during waxing?

YN
Are you using Retin-A, glycolic acid, or Accutane?

YN
EYELASH EXTENSIONS
Do you have eye conditions, infections, or recent eye surgeries?

YN
If you answer yes please explain
Do you wear contact lenses?

YN
Have you had a reaction to lash glue or lash extensions in the past?

YN
If you answer yes please explain
I understand that lash fills are recommended every 2 weeks to maintain fullness and lash health. Fills are designed to replace outgrown or shed lashes and keep the lash set looking fresh.

I acknowledge that:
If more than 3 weeks have passed, or if less than 40% of the lashes remain, it will be considered a full set and charged accordingly.
Timely maintenance is my responsibility to ensure proper lash retention and style consistency. Please sign your acknowledgement of the above information below.
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PERMANENT MAKEUP
Do you have a history of keloid scarring or slow healing?

YN
Have you had Botox or filler in the area in the past 4 weeks?

YN
Are you currently taking blood thinners (aspirin, warfarin, etc.)?

YN
*I understand that permanent makeup is a multi-step process that requires a mandatory follow-up session to achieve desired results. A 6-week touch-up appointment is required for optimal healing, color retention, and final results. Without this follow-up, results may be incomplete or fade prematurely.

I acknowledge that: The initial procedure may fade during the healing process. I am responsible for booking my 6-week touch-up appointment. Failure to attend the mandatory touch-up may result in unsatisfactory results, which I accept as part of my informed decision. Please sign your acknowledgement of the above information below.
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✅ FINAL CONSENT
Please read and confirm the following:

I confirm the information provided is accurate to the best of my knowledge.

I understand the nature and possible risks of the services I receive.

I agree to follow all aftercare instructions provided by my technician.

I release Petal & Bloom Spa from liability for any conditions arising from undisclosed information or failure to follow instructions.

I give permission for photos to be taken and used for marketing purposes, including social media and promotional materials.

Cancellation & Payment Policy Acknowledgment
-No-show or late cancellation fee will consist of 50% of total service cost.
-Payment due at time of service
-Refund policy (if applicable)
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Date

MonthDayYear
Date
Should be Empty: