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The Refresh Room

New Client intake form

At Tangles Hair & Beauty Salon, we require each new client to fill out an intake form before receiving any laser treatments at our salon. Please take a few minutes to fill out this form before your arrival, to ensure a more convenient and timely check-in.

PLEASE COMPLETE YOUR FORM HERE.

NEW CLIENT INTAKE FORM

New Client Intake Form

Date *

Month *

Day *

Year *

First Name *

Last Name *

Email Address *

Phone Number *

Date of Birth *

Month *

Day *

Year *

Occupation

Instagram

What is Your Preferred Method of Contact? *

TextPhone CallEmailInstagram

How Did You Hear About Tangles Hair & Beauty Salon?

Allergies.Please provide a list of any allergies or sensitivities that you may have.

Medications.Please list any medications and over the counter supplements, you may currently be taking, (Accutane, Antibiotics, Aspirin, Antiviral, Iron supplements, Gold therapy, Coumadin) Some drugs, vitamins, supplements and herbal remedies may cause photosensitivity. Dosages.

Dosages.Please list the dosage of all oral medications, and the date of the last dose taken.

Please Check All That Apply To You.

Skin disorders (e.g. keloids, abnormal wound healing)Current or history of skin cancer or other cancers or pre-malignant molesSevere concurrent medical conditions (e.g. cardiac disorders)Impaired immune systemVenous InsufficiencyDiseases stimulated by heat (e.g. Herpes Simplex)Active skin infection (e.g. psoriasis, eczema)Diseases stimulated by light (e.g. Lupus, Porphyria, Epilepsy)Endocrine disorders (e.g. diabetes, polycystic ovary syndrome)Pacemaker/DefibrillatorHistory of bleeding disordersTaken anticoagulants in the last 6 months

Please list any topical medications you are using.

Do you have any implants, superficial metal, injectables, or permanent make-up near the treatment area?

YesNo

If you answered yes, please list them below.

Do you have any tattoos or body piercings near the treatment site?

YesNo

If you answered yes, please list the location/s

Are you pregnant?

YesNo

Any chance of pregnancy?

YesNo

Tanning History.This includes direct sun, tanning bed, self-tanners, and spray tans. Please list and include the last date of use:

Previous Laser Treatments.If you have had any previous laser treatments either with Tangles, Hair & Beauty, or with another salon or clinic please specify the date of treatment, how many treatments you had, the frequency of the treatments, your tissue response, and what devise was used. (If known)

Previous Hair Removal History.

ElectrolysisWax/Sugar epilationMechanical epilation (tweezing/plucking)BleachingShavingOtherPlease check all treatments that apply.

If you answered Other, please list below.

How Often Do You Treat Your Unwanted Hair?Please list the frequency of your hair removal schedule, and the last treatment you used.

Have You Ever Had a Cosmetic Peel or Cosmetic Procedure?

YesNo

If you answered Yes, please list below.

Please List Any Other Treatments You May Have Received.

CONSENT *

YesI agree that the information listed above is to the best of my knowledge, truthful, and accurate. I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the technician of my current medical or health conditions and to update this history. Current medical history is essential for the caregiver to execute appropriate treatment procedures.

Signature *

Start signing your signature here

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