Name *
Name
Mailing Address *
Mailing Address
Home Phone
Home Phone
Cell
Cell
Work
Work
If Guest is under 18 years of age, Guardian Name:
If Guest is under 18 years of age, Guardian Name:
For your safety and well-being, we would like you to answer a few health-related questions. This information will remain confidential.
What are your concerns? *
Check all that apply.
Are you currently taking?
Please check all that apply.
Women Only
I would like to receive Atomic Beauty’s bi-monthly e-newsletter. *
Emergency Contact Information
Emergency Contact *
Emergency Contact
Telephone Number *
Telephone Number
Treatments, Procedures and Product Results
I have been informed of the extent and benefits of my desired treatment and/or procedure. I acknowledge that further treatments and/or procedures may be needed to acquire my desired results, which means additional costs may be accrued. I agree and accept that all treatments are not 100% guaranteed and are nonrefundable. I have also been informed of the recommended skincare products' benefits and proper use, as well as the potential risks and reactions that may occur. I recognize that results are not 100% guaranteed and are dependent on age, skin condition, and lifestyle. I have, to the best of my knowledge, given my full and accurate medical history including allergies and any prescribed medications (ingested or topical) that I'm currently using. If I have any additional questions or concerns regarding my treatment, procedure or suggested home care products, I acknowledge that I should contact my Atomic Beauty aesthetician immediately. I have read this agreement in its entirety. I hereby indemnify Atomic Beauty and my aesthetician, whose signature appears below, of any responsibility for my present medical conditions or aesthetic concerns not disclosed at the time of my treatment which may affect the performed treatment, procedures, or results from my recommended products.
I have read and agree to the above statement regarding the results of my recommended treatments and products. *
By submitting this form, you are agreeing you have read and understood the terms herein
Spa services are not covered by insurance. It is my understanding that, regardless of insurance coverage, payment for services rendered is my responsibility at the time of service.
Date *
Date
Your Legal Name, First & Last *
Your Legal Name, First & Last