NEW CLIENT FORM

Name *
Name
Date of Birth *
Date of Birth
Phone Number *
Phone Number
Address *
Address
Medical Information
(heart condition, surgery, varicose veins, cancer, etc.)
Emergency Contact
Name of Emergency Contact *
Name of Emergency Contact
Phone Number of Emergency Contact *
Phone Number of Emergency Contact
Service(s)
Service(s) of Interest *
Massage
Please answer the following questions if you are interested in our Massage service.
Eyelash Extensions
Please answer the following questions if you are interested in our Eyelash Extension service.
Please check the appropriate box(s) if you have an allergy to any of the following: