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. Once you start your services with Beautiful You by Profile you will be eligible for 3 to 9 visits to use within 12 months from date of first service.
Which Beautiful You location would you like to schedule your first appointment?*

Beautiful You by Profile Alpine location (Monday - Thursday by appointment)Beautiful You - Lemmen Holton Cancer Center (by appointment only)Beautiful You Boutique at Lacks (Cancer Center (by appointment only)Beautiful You Reed City-Susan P. Wheatlake Regional Cancer Center (by appointment only)
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Home Phone Number

Area CodePhone Number
Cell Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
Gender

MaleFemaleOther
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
Current treatment plan?*

RadiationChemoSurgeryMaintenance MedicationOther
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?
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 ApplicationOther
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?
At each appointment at Beautiful You by Profile you will be asked several questions to ensure your health and safety is not affected by the service we provide. We want you to be aware of the following when you are here.

Take note of the following when making appointments;

Chemotherapy: On the day before, day of and day after you receive chemotherapy treament you will only receive light touch on, hands, feet and scalp pertaining to any spa service at Beautiful You. Anything more than light touch will overwhelm your body.

Gamma Radiation: Please be advised if you are receiving radiation for two weeks after treatment no oil or lotion can be applied. Please disclose at check-in if you are receiving this treatment so our staff knows not to use product on the clients entire face.

If you are taking THIOPETA (also known as THIOPLEX) our staff will need to wear gloves while performing services. This medication has been suggested to exit the body via sweat.
I insert name here* have ready and understand the above statements related to my services at Beautiful You.
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: