New Client Intake Form

Customer Details:
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
As of today, I am over the age of 18:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
E-mail
You will recieve text messages & emails regarding your appointment and confirmations.
How did you hear about us?
Friend/other:
Emergency Contact

Area CodePhone Number
Do you have any allergies to any PLANTS, FRUITS, FLOWERS, OR SIMILAR? Any allergies to APIRIN OR OTHER MEDICATIONS?
Any other known allergies?
Are you currently using any RETINOL, LACTIC ACID, GLYCOLIC ACID, SALICYLIC ACID or any other NATURAL EXFOLIANTS? Any ACNE MEDICATIONS or home treatments?
Are you currently using a CLARISONIC or SCRUBS to manually exfoliate?
Have you ever gotten a COLD SORE/FEVER BLISTER?

Do you have any medical issues, are pregnant, or is there any other information that you feel your esthetician should be aware of?
What is your current skin care routine?
Treatment Consent

Please type your INITIALS if you agree.
I agree to follow all aftercare instructions as directed. Lacey Storm / Wonderland by Lacey Storm cannot guarantee the results of services if aftercare is not properly followed. I will contact Lacey Storm / Wonderland by Lacey Storm if I have any questions about aftercare.
I have disclosed any and all information relevant to my scheduled service and any future services performed by Wonderland by Lacey Storm. I will notify Lacey Storm / Wonderland by Lacey Storm of any future changes, so that I may receive the best possible service.
I understand that all appointments are subject to a 24-hour cancellation policy. If I should need to cancel my appointment, I will do so 24 hours in advance. Cancellations made within 24 hours before the appointment will forfeit their deposit. No shows will forfeit their deposit.
I agree that pictures may be taken for social media or progress purposes and I release these pictures to Lacey Storm / Wonderland by Lacey Storm.
Optional: Please add any additional information here that Wonderland by Lacey Storm and your esthetician/service provider should be aware of. (Please include parental/custodial consent for minors here by stating your name, child's name, and your legal consent)
I understand that the treatment I receive is provided by a licensed professional esthetician. If I experience any pain or discomfort during my appointment, I will immediately inform the practitioner so that the pressure and/or products may be adjusted to my level of comfort.

I further understand that any treatments should not be construed as a substitute for a medical examination, diagnosis or treatment and that I should see a physician or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that estheticians are not qualified to diagnose, prescribe, or treat any physical or mental illness and that nothing said in the course of a session should be construed as such. Because a treatment should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agreed to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioners and/or Wonderland by Lacey Storm's part should I fail to do so.

I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session and I will be liable for payment of the scheduled appointment.

No refunds will be given for services rendered. No refunds will be given for package sales or deposits. No refunds will be given for products sold once they leave Wonderland by Lacey Storm.

I have read and agree to the Cancelation & No-Show policy and associated fees.

Please sign below to signify that you agree to the above statements.
Signature
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Customer Details:

Treatment Consent