Date Of Appointment (Month/Date/Year) Full Name Date of Birth (Month/Date/Year) Address City State Zip Email Home Phone Work Phone Pls select your preferred method of communication for future appointment confirmation: - Select - Phone Call Email Text Service Being Issued: - Select - Color/Highlights Cut Perm Other Please answer the following questions in the space provided: In the past year, have you had any of the following services either in OR out of a salon? Haircut - Select - Yes No Permanent Wave/Texturizing Treatment - Select - Yes No Highlight or Lowlight - Select - Yes No Color Treatment - Select - Yes No Full Head Lightning - Select - Yes No Chemical Relaxing or Straightening - Select - Yes No Have you ever had an adverse reaction to any of the products, treatments or chemicals used during any salon service in the past? If yes, pls explain: Are you currently taking any medications? If yes, please list Were you referred to The Day Spa? - Select - Yes No If so, by whom I hereby indemnify The Day Spa/hair Technician from services stated and am fully aware and potential risks involved in the use of cosmetology products and chemicals used in this service. I state that I have no illness or health condition which might be aggravated or otherwise adversely affect the services being rendered. *Thank you for choosing The Day Spa for your hair care. For the maintenance and care of your hair following today’s color/chemical service, we advise the following: • Use only sulfate-free shampoo/conditioner. Professional products are available here for purchase/home use. • For best results, leave a minimum of one full week (7 days) before another chemical treatment. • If you are unhappy with your color for any reason, please contact The Day Spa as soon as possible. Our goal is your complete satisfaction. If over-the-counter color product/”box color” are used or if hair is tampered with post-service, we will not be able to adjust your color. The Day Spa does not offer cash refunds for hair services. You must agree before submitting. Electronic Aknowledgement Date Today (Month/Date/Year)
