Skin & Wax Intake Form

Full Name

First NameLast Name

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Date

How would you describe your skin type?

What are your main skin concerns or worries?

Have you undergone any of the following treatments within the past 4 weeks?

Have you undergone skin treatments before?

Do you have any allergies? Please list all known allergies.

Are you currently using any medications, topical treatments, or skincare products? (e.g., Accutane, tretinoin, etc.)

What is their preferred pressure for the neck/feet/face massage?

Are you pregnant, breastfeeding, or have any medical condition?

Emergency Contact

First NameLast Name

MOBILE SERVICE AGREEMENT

CLIENT INTAKE & TERMS OF SERVICE

Please review and sign the following mobile service policies prior to your scheduled treatment.

1. BOOKING & NON-REFUNDABLE DEPOSIT POLICY
Non-Refundable Deposit: A $10 non-refundable deposit is required at the time of booking to reserve your appointment slot. This deposit is applied directly toward your final service total.
Cancellations & Rescheduling: Cancellations or requests to reschedule must be made at least 24 hours prior to your appointment to transfer your deposit. Cancellations made with less than 24 hours' notice will forfeit the deposit.

2. PRE-ARRIVAL & SERVICE PREP WINDOW
Complimentary Setup Time: The provider will arrive 15–20 minutes prior to your scheduled service time to set up and sanitize equipment. This setup period is complimentary and does not count toward or reduce your active treatment duration.

3. TRAVEL FEES & DISTANCE BREAKDOWN
Travel fees account for transit and vehicle maintenance. Fees are calculated one-way from our base location and added to the final balance.
0–10 Miles: Included ($0), Standard Service Minimum.
11–25 Miles: $20 Flat Fee, Standard Service Minimum.

4. HOME SETUP & SPACE REQUIREMENTS
By signing below, you agree to provide an environment meeting the following conditions upon the provider's arrival:
Floor Space: A clear, clean area measuring approximately 6 ft × 8 ft for the portable treatment table and equipment.
Utilities: Access to a grounded electrical outlet (within 10 feet) and a sink with running hot water nearby.
Environment: A safe, climate-controlled, smoke-free space. Pets must be secured in a separate room for the duration of setup and treatment.

By signing below, I acknowledge that I have read, understood, and agree to the Mobile Service Agreement policies and home setup requirements above.

Mobile Esthetics Service Policy & Client Intake Agreement Page 1 of 1

Signature