Intake Form

What are you here for today? (Select all that apply)*

To select multiple services:
For windows: Hold down the control (ctrl) button
For Mac: Hold down the command button

Hair Removal Intake Form

Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 48-72 hours?*

Yes
No

Are you using Retin-a, Renova or Accutane (an oral form of Retin-a)?*

Yes
No

Have you used Retin-a, Renova or Accutane in the last 12 months?*

Yes
No

Are you using any other skin thinning products and/or drugs?*

Yes
No

Are you exposed to the sun on a daily basis or are you considering spending more time in the sun soon?*

Yes
No

Do you use a tanning bed?*

Yes
No

Please select any of the following that apply to you:*

Do you have any open skin lesions or active herpes outbreak (cold sore or genital)?*

Yes
No

Have you been waxed/sugared before?*

Yes
No

What areas?*

Have you had any of the following procedures? Select all that apply*

Chemical Peel
Laser Resurfacing
Removal of Skin Cancer
Microdermabrasion
None of the above

Any Other Major Exfoliation Procedure?*

Yes
No

How long ago and on what areas?*

Are you currently taking medications?*

Yes
No

Please list all (including over the counter drugs/herbal supplements):*

What skin products do you regularly use on your skin?*

Have you ever been treated for cancer? If yes, when and what types of therapies were used?*

Please list any other illness/condition you are currently being treated for by a medical professional*

Please list any and all allergies you have:*

(Female clients) When is your next menstrual cycle due to begin?

(Always allow five days for menstrual cycle. Because of water retention and for your own personal comfort, you should avoid hair removal two days before your cycle is due and two days after it is completed.)

Cancellation Policy/Fees

• Your appointment time was specifically reserved for you, so the courtesy of 24 hour notice for cancellation or rescheduling is appreciated.

• For all new clients, appointments over 90 minutes, couples, and packages; if you fail to give less than 6 business hour notice of cancellation, you will be billed the full price of the treatment scheduled. If it is a morning appointment, we must receive your call by the afternoon before to avoid the fee.

• For all existing clients; if you fail to give less than 1 business hour notice of cancellation, you will be billed the full price of the treatment scheduled. If it is a morning appointment, we must receive your call by the end of the prior business day to avoid the fee.

• Phone call, e-mail, and text message reminders will be provided as a courtesy to you. If you opt out of phone call reminders; please be aware that an automated system sends our e-mails and text messages and we cannot guarantee their reliability; it is your responsibility to remember your scheduled appointments. You can update your reminder method with our front desk staff at any time if your preferences change.

• Bounced checks will incur a $25.00 fee for which a bill will be sent.

Treatment Policies and Etiquette

These policies are in place for your personal protection as well as for the professional dignity of the therapist. You will receive personal instructions on what clothing to remove and how to prepare for the treatment. Please follow those instructions as well as the guidelines that follow:

• Always wait for the therapist to leave the room before getting undressed. Keep a lower undergarment on and cover yourself with the sheet as instructed. You will not be exposed by the therapist during the treatment, and should not attempt to expose yourself. Please do not get off the table at the end of the treatment until the therapist has left the room.

• At no time will any sexual comments, suggestions, activities, or requests be tolerated. If this term is violated, the therapist has the right to end the session, full payment is required, and no further treatments will be scheduled. This is a zero tolerance policy.

Please note that waxing/sugaring does have certain side effects such as skin removal, redness, swelling, tenderness, etc. Please initial each of the following in agreement with the statements.

• I have read the above information and if I have any concerns, I will address these with my skin therapist.*

• I give permission to my therapist to perform the waxing procedure we have discussed and will hold her and her staff harmless from any liability that may result from this treatment. *

• I have given an accurate account of the questions asked above including all known allergies or prescription drugs or products I am currently ingesting or using topically. *

• I understand my esthetician will take every precaution to minimize or eliminate negative reactions as much as possible. *

• I have read and understand the post-treatment home care instructions. *

• I am willing to follow recommendations made by my esthetician for a home care regimen that can minimize or eliminate possible negative reactions. *

• In the event that I may have additional questions or concerns regarding my treatment or suggested home product / post-treatment care, I will consult the esthetician immediately. *

• I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. *

• I understand the procedure and accept the risks. *

• I do not hold the esthetician, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today.*

We have the right to refuse services for all waxing if proper hygiene is not followed. For Brazilian and bikini waxes, please use the provided wipe to cleanse area.

Type Client Name*

Client Signature*

Today's Date*

MM

DD

YYYY

Lashes Intake Form

Do you have any signs of illness? (Examples: Red eyes, stuffy nose, seasonal allergies, etc.)*

Yes
No

Please Describe*

New medications, vitamins or herbal supplements since last visit?*

Yes
No

Please List*

Were any allergies discovered since your last visit? (Includes adverse reactions experienced)*

Yes
No

Please List*

Are you pregnant?*

Yes
No

Due Date*

MM

DD

YYYY

Are you on a new diet?*

Yes
No

Please Describe*

Do you exercise regularly?*

Yes
No

Type/Frequency*

Do you wear daily disposable, extended wear or permanent contact lenses?*

Yes
No

If daily disposable, bring eyeglasses?*

Yes
No

Have you used any new facial or eye products since your last visit?*

Yes
No

Please List*

Have you had your eyelashes tinted in the last 4 weeks?*

Yes
No

Have you had any procedures completed on your face or around your eyes within the last 48 hours? (Includes permanent cosmetics, skin-resurfacing, tinting, perming, surgeries, etc.)*

Yes
No

Please Describe*

When was the last time you wore cosmetic products on your face or around your eyes? (Include all worn within the last 3 days)*

Type of look desired by client:

Increase in length*

Subtle
Noticeable
Dramatic

Increase in volume*

Subtle
Noticeable
Dramatic

Other design requests:

Signature*

Today's Date*

MM

DD

YYYY

Massage Intake Form

Have you ever had a massage before?*

Yes
No

What brought you in today?*

Therapy
Pain Relief
Injury
Relaxation
Other

Please provide details:

Please describe your main concern for today's treatment.*

Please list any surgeries or medical procedures you have had along with the year it took place.*

Are you taking any of the following:*

Asprin
Anti-inflamatory
Pain relieving narcotics
Cholesterol Medication
Blood Pressure Medication
Thyroid Medication
Cancer Treatment Drugs
None of the Above

Check any of the following Respiratory or Circulatory issues you have or experienced in the past:*

Asthma
COPD
Hyper tension
Low Blood Pressure
Diabetes
Deep Vein Thrombosis (DVT)
Heart Condition
Pacemaker
None of the Above

Check any of the following Nervous, Skin or other issues you have or have experienced in the past:

Are you pregnant?*

Yes
No

What is your due date?*

MM

DD

YYYY

Cancellation Policy/Fees

Your appointment time was specifically reserved for you, so the courtesy of 24 hour notice for cancellation or rescheduling is appreciated.

For all new clients, appointments over 90 minutes, couples, and packages; if you fail to give less than 6 business hour notice of cancellation, you will be billed the full price of the treatment scheduled. If it is a morning appointment, we must receive your call by the afternoon before to avoid the fee.

For all existing clients; if you fail to give less than 1 business hour notice of cancellation, you will be billed the full price of the treatment scheduled. If it is a morning appointment, we must receive your call by the end of the prior business day to avoid the fee.

Phone call, e-mail, and text message reminders will be provided as a courtesy to you. If you opt out of phone call reminders; please be aware that an automated system sends our e-mails and text messages and we cannot guarantee their reliability; it is your responsibility to remember your scheduled appointments. You can update your reminder method with our front desk staff at any time if your preferences change.

Bounced checks will incur a $25.00 fee for which a bill will be sent.

Treatment Policies and Etiquette

These policies are in place for your personal protection as well as for the professional dignity of the therapist. You will receive personal instructions on what clothing to remove and how to prepare for the treatment. Please follow those instructions as well as the guidelines that follow:

1. Always wait for the therapist to leave the room before getting undressed. Keep a lower undergarment on and cover yourself with the sheet as instructed. You will not be exposed by the therapist during the treatment, and should not attempt to expose yourself. Please do not get off the table at the end of the treatment until the therapist has left the room.

2. At no time will any sexual comments, suggestions, activities, or requests be tolerated. If this term is violated, the therapist has the right to end the session, full payment is required, and no further treatments will be scheduled. This is a zero tolerance policy.

I have read and agree to the above terms:*

File

Phone

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Step 1 of 2

Personal Information

Address Verification and Medical History Update Form

Hair Removal Intake Form

Cancellation Policy/Fees

Treatment Policies and Etiquette

Please note that waxing/sugaring does have certain side effects such as skin removal, redness, swelling, tenderness, etc. Please initial each of the following in agreement with the statements.

Lashes Intake Form

Type of look desired by client:

Massage Intake Form

Cancellation Policy/Fees

Treatment Policies and Etiquette

Salus Massage Therapy

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