Hair, EyeLash, & Barber Client Intake Form
Please print and complete this intake form for hair, eyelashes, and barber services. This is a confidential client health intake. Your information will not be shared with third parties. Forms must be completed, dated, and signed before services can be rendered. See Spa Intake page for spa and massage services. For all other services visit our Forms page.
Name ______________________________________ Date __________________
Mailing Address _______________________________________________________
City _____________________ State _______________________ Zip ____________________
Address of service appointment: ____________________________________________________________________________
Work Phone_____________________ Home Phone____________________
Cell __________________ Phone_____________________ Date of Birth_________________
Emergency Contact (optional): ___________________________________________________
Phone: _____________________ Relation: _________________________________________
CURRENT HEALTH ISSUES
1. What is your main reason for having a mobile care session? What would you like to achieve today? ____________________________________________________________________________
2. List any other health problems that are troubling you. ____________________________________________________________________________ ____________________________________________________________________________
3. Are you currently taking any prescription drugs and if so what are they? Please list below including any new medications since your last visit. Some prescription drugs can be affected by services. ____________________________________________________________________________________ ____________________________________________________________________________________
4. Check all that apply:
___ Acne ___Claustrophobia ___Epilepsy ___Pregnant ___Arthritis Diabetic ___blood thinners
___nail disorders ___contact lenses ___psoriasis ___HIV ___steroids ___Anti-coagulants
5. Have you seen a Dermatologist in the past 5 years? ___Yes ___ No
Are you under his/her care? ___Yes ___ No
Give Doctor’s Name: __________________________ Phone: _________________________
6. Have you ever had a professional stylist/barber/artist/technician for this service recently?
Yes ___ No ___
If yes, what did you like or dislike about the service? ____________________________________________________________________________________
7. Have you used any of the following in the last 14 days? Yes_____ No_____ Check all that apply.
___ Retin-A ___Renova ___Accutane ___ Glycolic ___Other
8. Are you sensitive to fragrances, perfumes, oils, lotions, or any other products the technician should be aware of? Yes_____ No ______ List______________________________________________________________
9. Are you allergic to latex, epinephrine, citrus, sulfa, collagen, glycerin, or any allergy the technician should be aware of? Yes_____ No______
Please List: ____________________________________________________________
10. Do you have sensitive skin? Yes____ No____
(Please list areas) _____________________________________________________________
11. Have you ever had an allergic reaction to any type of skin care product? List products. ____________________________________________________________________________
12. Are you currently using any skin care products? Yes ____ No ____ List products:____________________________________________________________________________
13. Do you work near a UV source or use a tanning bed? ___Yes ___ No
14. Do you have a pacemaker? ___ Yes ___ No
15. Do you have any metal implants in your body? ___ Yes ___ No
16. Any recent surgery, including plastic surgery in or near the being serviced. ___ Yes ___ No
17. Any scalp problems, skin disorders, or skin cancers? ___ Yes ____ No
Please, List: __________________________________________________________________
18. Do you wear contact lens? ____ Yes ____ No
19. Are there certain brands of products or chemicals that irritate your skin or scalp? If so, List below.
20. What is your current shaving method or system? ___ Wet shave ___Electric
21. Do you experience irritation from shaving? ____ Yes ____ No22. Explain anything else you think we should know: ____________________________________________________________________________ ____________________________________________________________________________
I understand and accept the terms and conditions of Ecstasy’s Hair & Spa. I understand that it is my responsibility to make any health conditions, allergies, or other related issues to the stylist or technician. I agree to allow Ecstasy’s Hair & Spa to take and use photos and/or video of before and after services. I agree that Ecstasy’s Hair & Spa may reasonably advertise the photos or videos for the sole purpose of referencing, advertising, marketing, and promotions. I confirm to the best of my knowledge that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. If I decide on a treatment against the advice of an Ecstasy’s Hair & Spa professional based on my skin conditions or health history, I take full responsibility and will not hold Ecstasy’s Hair & Spa liable.
Client Name (print):___________________________________ Date: _____________________
Client Signature: _________________________________
Authorizing Signature (card holder): ________________________________ Date: ___________
Stylist or Technician (print): ________________________________
Stylist/Tech. Signature: ________________________________ Date: _____________________
Ecstasy's Skin Care Record - Completed by technician, please initial each entry.
Brand of Products Used
Product Record - Please initial each entry.
Purchased Samples Given
DO NOT WRITE BELOW THIS LINE (to be completed by office staff only)
I.D. Number: ________________________ State Issued: ________
Type of I.D. _________________________ Client Name: ______________________________
Did you confirm that the name on the appointment and client intake form matched the name on the identification? Yes ___ No___
Did you confirm the card holder’s identification? Yes ___ No ___
Did you obtain the authorizing signature of the card holder?
Appointment Start Time ____:____ am pm End Time ____:____ Service Duration ___min. ___hrs.
Signature: _______________________________ Date: ____________________
Please have client to complete the section below or auto-submit an evaluation form on the website.
Client Evaluation Section (optional, not required)
1) How would you rate or describe the services you received? Bad Poor Average Good Excellent
2) Did you receive a service receipt? Yes ____ No ____ Pending Email Delivery ____
3) Did the service technician arrive on time? Yes_____ No_____
4) What your service total amount? $_______ . _______
5) What was your form of payment? ___cash ___debit ___credit ___pay pal ___ other
6) How would you rate or describe the overall customer services you received?
Bad Poor Average Good Excellent
***If you did not receive a service receipt, have any comments or complaints that you have not disclosed here, please email email@example.com or see our contact page.
Client Signature: _________________________________________ Date: _______/_______/_______
First Visit Date ______/_______/_______ Current Date ______/_______/_______