Guest registration form

All information is confidential

Personal history

Client name ______

Date of birth ______Age ______Occupation ______

Home address ______

Best contact number ______type: _____ home _____ work _____ cell

May we leave a voice message? _____yes _____ no

If cell, may we leave a text to confirm appointments? _____yes ____no

Email address ______

May we use this address to send you treatments specials products discounts? _____yes _____no (We do not sell or disclose this information to anyone.)

Emergency contact name and number ______

How did you hear about us? ____ Yelp _____Family/friend _____Google search _____Facebook

_____ Instagram _____Twitter _____other ______

If referred by a friend/family member please give us their name as we offer discounts for referrals! ______

Medical history:

Are you under the care of a physician? _____yes _____no

If yes, for what ______

Do you have any of the following conditions? Please check any that apply.

____ Cancer _____Diabetes _____High blood pressure _____Frequent cold sores _____Arthritis

_____ HIV/AIDS _____Keloid scaring _____Skin disease/lesions _____Hepatitis A,BorC

_____ Hormone imbalance _____Thyroid imbalance _____Blood clotting abnormalities

_____Asthma _____Emphysema _____Neuromuscular disorders _____Autoimmune disorder

_____ Heart disease _____other _____please explain ______

Allergies:

Do you have any known allergies or sensitivities? Please check any that apply.

_____ Food _____Aspirin _____lidocaine _____Hydrocortisone _____Hydroquinone _____Retin A

_____ Latex _____other please explain ______

Medications: Are you on internal medications? Please check any that apply.

____ Birth control pills ____Hormone replacement ____Blood thinners (aspirin, Coumadin, Vitamin E, Plavix® etc) _____Herbal supplements (GinkoBiloba, St John’s Wort etc) ____ Accutane within 6 months

Topical medications (for skin care clients) Are you using a prescription product on your skin?

_____ RetinA _____Differin _____Topical antibiotics _____Hydroquinone

For waxing clients: please let us know with each visit if you are using anything topical from your doctor.

For women only:Check all that apply

_____Regular periods _____going through menopause _____Melasama from pregnancy

For men only: Check all that apply

___ shave daily ___razor bumps ___ingrown hairs on face

Esthetic history: Check what you have experienced:

_____Facials _____Microdermbrasion _____hydrafacial _____Acne treatments _____Face waxing

_____Body waxing _____Botox _____Fillers _____Permanent cosmetics, microblading _____Peels _____Massage therapy _____Acupuncture _____Skin resurfacing _____Skin tightening

Sun History:

Do you work in the sun? _____yes _____no

Do you use sunscreen? _____yes _____no _____occasionally

For Esthetic clients: How do you tan?

_____Burn _____Burn then tan _____usually tan _____always tan

Do you have pigmentation concerns?

_____Even skin tone _____Pregnancy mask _____Sun damage

Vascularity concerns: Do you have broken capillaries on:

_____your nose _____Cheeks _____Chin _____Forehead _____entire face

What is your daily skin care regimen? ______

______

For massage clients: Do you currently have

_____Muscle strain _____Dry uncomfortable skin _____Stress _____Poor circulation

Is there a particular area that bothers you today?

______

Appointments/cancellations/no shows

  • Due to the popularity of our unique services, we highly recommend you make your reservation in advance.
  • Due to our intimate size, cancellations of less than 6 hours notice will incur charges equal to 50% of the service booked or one session will be redeemed for any prepaid treatments.
  • Any no shows will incur a 50% charge.
  • Please arrive 5-10 minutes prior to your reservation to allow time for check-in and a few moments to relax. Appointments cannot be extended due to late arrivals and will shorten the duration of the service.

Skin Sensitivities

  • To avoid adverse reactions, please notify us of any medications you are using, including anything from a dermatologist and remind us of this prior to each service. We would rather err on the side of caution.
  • If you have any sensitivities or allergies to products or ingredients, please remind your esthetician each time prior to your service. Once again, we would rather be overly cautious than overconfident.

Other Policies

  • We recommend you not bring valuables with you for your treatment. We are not responsible for lost or misplaced items.
  • Gift certificates may be transferred, but not refunded.
  • A $15.00 charge will be incurred for return checks.
  • Price lists are available at the front desk.
  • Merchandise credit or exchanges given upon approval.
  • Unfortunately, cash refunds cannot be given.
  • We reserve the right to refuse service to any individual.

Pictures will occasionally be obtained for our records. In the event a picture is used for educational or marketing purposes, identifying features will be removed. Please initial to acknowledge this notice. _____

I acknowledge that the practice of skin care including micro-current treatments, microdermabrasion, ultrasound treatments, LED treatments, chemical peels, enzyme peels, facials, lasers, IPL, massage therapy and body treatments, and other various beauty treatments is not an exact science and that no specific guarantees can or have been made concerning the expected result. I understand that some clients experience more change and improvement than others. In virtually all cases, multiple treatments are required in order to realize a difference.

I also understand that the following risks and hazards may occur in connection with any particular treatment – included but not limited to: unsatisfactory results, poor healing, discomfort, redness, blistering and scarring. I understand that even though precautions may be taken in my treatment, not all risks can be known in advance.

Given the above, I understand that response to treatment varies on an individual basis and that specific results are not guaranteed. I also agree to hold harmless and release Helen’s Haven and ValorieAmmann,MD , its officers and its employees from any liability for any condition or result, know or unknown that may arise as a result of any treatment that I receive.

Signed ______

Date ______