New Client Intake Form

Name*

Address*

Email*

Phone*

Date*

Occupation*

Name*

Phone*

Message*

Please answer the following questions to the best of your knowledge in order to provide you with the best service:

Have you ever had a professional waxing or sugaring treatment?*

Yes
No

Have you ever had an adverse reaction to sugaring or waxing?*

Yes
No

Have you had a peel, microdermabrasion or tanned in the past 48 hours?*

Yes
No

Please list any areas you would like specific attention to during your waxing treatment?*

Do you have any allergies? (Product ingredients, foods, plants/herbs, latex, etc.)*

Do you have any of the following conditions? (Check any that apply)*

Any other conditions/illnesses/infections not listed:*

Are you currently under the care of a Dermatologist?*

Yes
No

If so, for what?*

Are you currently pregnant?*

Yes
No

How many weeks? *

Do you have any specific concerns your esthetician should be aware of? *

Are you taking any of the following medications? (Check all that apply):

If other, please list below:*

Consent*

I agree to all MKP WAXING SALON, LLC's Release & Waiver of Liability, as well as all Cancellations & No-Show Fee Policies Outlined Below.

I certify that the above statements are true and correct and that I, have been informed by my esthetician of the nature of the services(s) being provided. I, understand that waxing treatments performed at MKP Waxing Salon, LLC are for the sole purpose of hair removal, with awareness that certain side effects of waxing such as skin removal, redness, swelling and tenderness are possible. I understand that my esthetician is not a physician and cannot diagnose or prescribe towards any medical condition or disease. I understand that it is my
responsibility to notify my esthetician of any changes in my health or medical history. I understand that it is ultimately my responsibility to notify my esthetician if I am ever in discomfort or pain. I understand that any soreness or adverse medical condition incurred during my waxing treatment will be my fault alone. I hereby state that I have read the information above and have provided MKP Waxing Salon, LLC with all notable information to the best of my knowledge.

MKP WAXING SALON, LLC
RELEASE & WAIVER OF LIABILITY

Physical condition/Assumption of Risk: All Salon services are offered under the understanding, assumption and agreement of Client that Client is in adequate physical shape and under no ailments or impairments to receive the services requested by Client. Notwithstanding the care taken by MKP Waxing Salon, LLC and its agent, employees, and independent contractors to avoid injury, Client understands that various procedures may cause rashes, redness, bruises, swelling, skin irritation, minor bleeding, temporary soreness, and infection, and may be impacted further by conditions of the procedures to be undertaken, along with all risk of any complications associated with preexisting health or medical conditions of the Client. Client acknowledges that Client has been warned of the potential dangers involved in such Salon services and Client undertakes such activities voluntarily, thereby assuming all risks involved.

Non-Medical Treatment. Client understands that Salon estheticians do not diagnose illness, disease, or other physical or mental disorders, or prescribe medical treatments or pharmaceuticals and that the services rendered in the Salon are not medical in nature and are not a substitute for diagnosis and treatment by a licensed medical professional.

Questionnaire. Client acknowledges and represents that the questionnaires and profiles required to be filled out will be used to determine if there are any known conflicts between the services to be received from the Salon and the Client’s known medical conditions. Client represents that such questionnaires and profiles are filled out accurately and understand the Salon may refuse service if the same is not completed.

Disclaimer of Liability: Client acknowledges that all Salon services involve a risk of injury, including in extreme rare cases resulting from severe allergic reactions or infections, the possibility of death, and Client undertakes such activities voluntarily thereby assuming all risks involved. Client assumes for him/ herself and his/her heirs, successors and assigns all liability for any injury (including disability and death) that he/she may incur as a result of Salon services, including those attributable to ordinary negligence of Salon. Salon shall have no liability whatsoever to any Client or Client’s heirs, successors or assigns, for any illness or injury (including an illness or injury which results in disability or death) arising out of or attributable to any Salon services. Client specifically agrees to hold Salon, its officers, managers, members, owners, agents, employees, independent contractors, representatives, and assigns, harmless for any loss to the person or property, sickness, injury, partial or permanent disability and death such that Client may sustain as a result of receiving Salon services.

Governing Law. This and each document required to be signed by any participant, and any dispute that arises, shall be governed by and construed in accordance with the laws of the State of Georgia. If any part of this waiver shall be determined to be invalid, the balance shall continue in full force and effect.

The undersigned states that he or she freely and voluntarily executes this Agreement and asserts that he or she understands all the terms used herein, and the consequences thereof. The undersigned acknowledges that this Agreement is binding upon the heirs, administrators, executors, successors and assigns of the undersigned.

CANCELLATIONS & NO-SHOW FEE POLICY AGREEMENT

Same Day Cancellation/rescheduling: If my appointment is canceled or rescheduled within 24 hours or less of my appointment time, I understand that I will be assessed a fee equal to 50% of the total cost of any and all services scheduled. If the card on file is declined, I understand that I cannot book another appointment until the fee has been paid.

No show fee: I acknowledge that if I do not call nor show up for my appointment, I will be charged a NO-SHOW FEE equal to 50% of the total cost of any and all services scheduled. If the card on file is declined, I understand that I cannot book another appointment until the fee has been paid. I am also aware that after two NO-SHOWS I will no longer be able to book an appointment without a 50% deposit on whichever service is being requested.

I acknowledge and agree to the terms of the same-day cancellations and the no-show policy stated above.

Consent*

I agree to all MKP WAXING SALON, LLC Photography and Videography Policies Outlined Below.

For the privacy and safety of our guests and employees, no photography or videography is allowed inside of our service rooms. Guests found to be breaking this policy will be permanently banned from our salon. An exception will be made if a guest is participating in "before and after" photos that have been commissioned by a staff member at the salon.

Phone

This field is for validation purposes and should be left unchanged.

MKP WAXING SALON, LLC CLIENT INTAKE FORM

MKP WAXING SALON, LLC
CLIENT INTAKE FORM