Client History Form
6345 South Pecos Rd #107, Las Vegas NV 89120 (Inside Alexander's Holstic Center)
Date of Birth
Street Address Line 2
State / Province
Postal / Zip Code
Antigua and Barbuda
Bosnia and Herzegovina
Central African Republic
Cocos (Keeling) Islands
Democratic Republic of the Congo
Turkish Republic of Northern Cyprus
Papua New Guinea
Republic of the Congo
Saint Kitts and Nevis
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Sao Tome and Principe
Trinidad and Tobago
Tristan da Cunha
Turks and Caicos Islands
United Arab Emirates
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
How did you hear about us?
Would you like to receive text messages (once a month) about specials and deals? Text "AZUL" to 55222 to be subscibled into the VIP List! Or I can add you manually.
Yes! Add me
What are your skincare goals?
Are you allergic to anything?
What is the #1 thing you would like to change?
Are you currently using any of the following products now or in the past 2 weeks?
None of the above
Are you on any prescription medication? If yes, please list. (Some medications can affect your treatment/skin. It's very important to list)
Have you been exposed to the sun or tanning bed in the last 48 hours?
Do you smoke?
Check the following that apply to you:
Wear eye contacts
Low or High Blood Pressure
None of the above
Are you pregnant or trying to become pregnant?
Are you taking any oral contraceptive?
Are you experiencing any menopause issues?
Last menstrual cycle?
Photo Release I give Azul Organic Skincare by Jessica permission to use my pictures of my treatment progress for marketing purposes in social media, brochures and posters.
I hereby consent to authorize Jessica @Azul Organic Skincare inside Alexander's Holistic Center to perform the facial/body treatment. I have to the best of my knowledge given an accurate account of my medical history, including all known allergies or prescription drugs or products I am currently ingesting or using topically. I have read and fully understand this agreement and all information detailed above. I understand the procedure and accept the risks. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I do not hold the esthetician Jessica, whose signature appears below, responsible for any of my conditions that were present and release my esthetician from liability's and assume full responsibility. I recognize there are no guaranteed results and that independent results are dependent upon age, skin condition, and lifestyle and that there is the possibility I may require further treatments of the treated areas to obtain the expected results at an additional cost. I understand that waxing may cause bruising, scabs, redness, breakouts or pimples and are normal reactions to the skin. I understand that the use of any chemical peels, microdermabrasions, tanning, prescription drugs or any topical cream can affect and postpone any facial/waxing/body treatments. Although it is impossible to list every potential risk and complications, I have been informed of possible benefits, risks, and complications. I agree that ALL specials i.e. groupons, living social and yelp are one time deals per person only. Azul Organic Skincare inside Alexander's Holistic Center is not responsible for lost or stolen property's. Azul Organic Skincare has a strict 24 hour cancellation policy and in the event of a "no show" a fee of $15 will be charged via square. Aesthetician Jessica C.
Yes, I agree
No, I do not agree
Minor Consent Form (Under 18 years of age)
Minors who are under 18 years of age are permitted to receive a treatment in the spa. Parent or legal guardian must be present in helping complete the Health History Form for the minor, along with consent for the treatment. Appropriate draping will be used at all times during the spa treatment, only areas being treated are uncovered. I am the parent/legal guardian who's name appears on this client form and I have read the above information and give permission for my child, who is under age to receive a spa treatment from Azul Organic Skincare by Jessica inside Alexander's Holistic Center.
Name of Parent/Guardian
Yes, I allow my child to receive spa services
No, I do not want my child to receive spa services.
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