Client Intake Form

Client Intake Form
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Service Selection
Medical History
Do you have any Allergies? If yes, please List below:
Lash Extension Client
Have you had lash Extensions before?
Do you currently have Lash Extensions on?
Have you ever experienced any reactions to lash adhesive?
If yes, please explain
Brow & Wax Clients
Have you used any of the following within the last 7 days?
Photography Release
I authorize Allure Esthetics Beauty to photograph my results from social media, marketing, and educational purposes.
Consent & Liability Waiver
I understand that while every precaution is taken to ensure my safety, reactions may occur due to allergies, sensitivities, or unforeseen circumstances. I have disclosed all known medical conditions and allergies that may affect my service. I understand results vary from person to person and that proper aftercare is my responsibility.

I consent to receive services from Allure Esthetics Beauty.
Client Signature:
Date

MonthDayYear
Date
Should be Empty:

Emergency Contact