New Client Application

Apply NOW for the Beautiful You Program:

Beautiful You by Profile is honored to treat you during this difficult time. We are happy to provide you with complimentary services during your treatment. No information submitted on this form will be shared with outside sources. Once you submit your application someone from our team will be in contact with you.
Which Beautiful You location would you like to schedule your first appointment?*

Beautiful You Alpine Location (Monday-Thursday 9am-3pm-by appointment only)Beautiful You Lemmen Holton Cancer Pavilion (Tuesdays 9am-2pm by appointment only)Beautiful You Mercy Health- Lacks Womens Boutique (Thursdays 9am-4pm -by appointment only)
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Cell Phone Number*

Area CodePhone Number
Home Phone Number

Area CodePhone Number
E-mail
Gender

MaleFemale
Race

WhiteBlackBi RacialAsianLatinoPacific IslanderNative AmericanOther

Additional contact person:

	Name	Contact Number	Relationship to you
1
2

Marital Status

MarriedSingleDivorcedWidowedOther
When were you diagnosed with cancer?(Estimated date is fine)*

MonthDayYear
Date
When did / do you start treatment? (Estimated date is fine)*

MonthDayYear
Date
Anticipated End of Treatment?*

MonthDayYear
Date
Rate your support system 1-10 ( 10 being the strongest)
Type of Cancer*
Any additional information you would like to provide regarding your type of cancer?
Current treatment plan?*

RadiationChemoSurgeryMaintenance Medication
Where are you receiving treatment: (Name of Medical Facility)
Name of Oncologist/Doctor: Optional
Please list any medications that may cause reactions to skincare, makeup or haircare products)
To help us better serve you in scheduling your first appointment, please choose below the services that you are in immediate need of:*

WigHead shaveConsultation with stylistHead cover/hatEyelash & Eyebrow Application
Do you have any known sensitivity or reactions to skincare, make-up or hair care products?
Do you have any other medical conditions we should be aware of?
I, First Name Last Name in order to be considered and receive services for the Beautiful You Program, agree to hold harmless and release Beautiful You By Profile as well as its officers, directors, employees, agents and volunteers from any and all liability, damages, claims, causes of action, cost and/or expenses of any kind or nature, whether known or unknown, that may arise from or relate to any salon service, spa treatment, or other service that I may receive from any of the foregoing released parties.
Signature

Clear
Photographic Consent- By checking the YES box below I am granting permission to Beautiful You by Profile to use, without compensation, photographs of me for the purpose of bringing awareness to the program, fundraising, advertising, promotions, and/or any other purpose consistent with the charitable mission of the organization. You may check NO if you do not want your picture used other than to identify you by.*

YESNO
Take Photo
Taking your photo for application submission is voluntary & will only be used to help us identify you for your appointment. With numerous clients visiting our offices it is helpful for us to identify clients as they enter our facility.
Should be Empty:

Apply NOW for the Beautiful You Program: