iModel Intake Form

Full Name (Last, First, MI.)(Required)

Date of Birth(Required)

Gender(Required)

Date(Required)

Email(Required)

Height(Required)

Weight(Required)

Phone Numbers Provide your contact number(s) and check the box below for your preferred contact number. May we leave a detailed message?

Home

Mobile(Required)

Work(Required)

May we leave a detailed message?(Required)

May we leave a detailed message?

Yes

Home Address / City/State / Zip Code(Required)

Emergency Contact

First Name(Required)

Last Name(Required)

Phone

MEDICAL HISTORY(Required)

Select past and present medical conditions you have experienced:

Cancers Other Than Skin: Include type/location and treatment(s)

Additional Medical Conditions:

Are you pregnant or breastfeeding?(Required)

Yes

When was your last Menstral Period?(Required)

None or List Past Surgeries:

None

Skin Disease History(Required)

None or List All Skin Diseases and/or Disorders:

Do you wear Sunscreen?

Yes

If yes, what brand/SPF?

Tanning salon usage?

Yes

Do you have a family history of Melanoma?

Yes

If yes, which relative(s)?

Medication History

List all medication names and dosages including over the counter, herbal supplements, prescription creams & skin care products. (Examples: Retin-A, Renova, Differin, Tazorac, glycolic/AHA products)

Social History

Do you use tobacco products?(Required)

Yes

If yes, what type & how much?

Do you consume alcohol?(Required)

Yes

If yes, how often & how much?

What is your occupation?

Cosmetic History

Have you had any plastic surgery?(Required)

Yes

If yes, what type/when?

Is this your first Brazilian Wax?(Required)

Yes

If yes, what type/when?

Have you had Botox or Dermal Fillers?(Required)

Yes

If yes, when?

Have you had Laser Hair Removal?(Required)

Yes

If yes, when/what area(s) of your body?

Have you had any permanent makeup?(Required)

Yes

No If yes, when/what area(s) of your face?

Please list any other cosmetic procedure you've had in the past or receive regularly

Skin Concerns

Please check any cosmetic services you are interested in receiving or learning about:

If other Skin Concerns

Cosmetic Interests

If other Cosmetic

Your appointments are of high importance to us. We realize that at times unexpected circumstances may require schedule adjustments. If you need to cancel an appointment, we respectfully require that you provide at least 24 hours notice.

Our Policy:

A cancellation or request to reschedule made less than 24 hours in advance of your appointment time will invoke a cancellation fee, or forfeit of the pre-paid deposit. The amount charged will be equal to 10% of the booked services.

A deposit is required to make an appointment. Should there be no issues with the appointment, the deposit will be used towards payment of your services. However, if a cancellation or request to reschedule is made less than 24 hours in advance of your appointment time, the deposit will not be returned and be kept by iModel Beauty Bar as a cancellation fee.

Please reach out with questions and concerns.

Print Name:(Required)

Signature(Required)

Date(Required)

COVID-19 LIABILITY RELEASE WAIVER

THIS FORM MUST BE COMPLETED AND SIGNED BEFORE TREATMENT

The World Health Organization has declared the novel Coronavirus (COVID-19) a worldwide pandemic. Due to its capacity to transmit from person-to-person through respiratory droplets, the government has set recommendations, guidelines, and some prohibitions which

Recommendations, Guidelines

adheres to comply.

Symptoms of COVID-19 include:

Fever
Fatigue
Dry Cough
Difficulty Breathing

I agree to the following 1:

I, nor members of my household, have not experienced any of the symptoms listed above within the last 14 days

I agree to the following 2:

I, nor members of my household, have not travelled internationally in the last 30 days.

I agree to the following 3:

I, nor members of my household, do not believe that we have been exposed to someone with a suspected and/or confirmed case of the Coronavirus (COVID-19).

I agree to the following 4:

I, nor members of my household, have not been diagnosed with the Coronavirus (COVID-19) within the last 30 days.

I agree to the following 5:

The venue cannot be held liable from any exposure to the Coronavirus (COVID-19) caused by misinformation on this form or the health history provided by each client

I agree to the following 6:

I understand that due to the frequency of visits of other clients, the characteristics of the virus, and the characteristics of these services that I have an elevated risk of contracting the virus simply by being in the establishment.

To prevent the spread of the contagious virus and to help protect each other, I understand that I must follow the establishment's guidelines:

Reschedule appointment if you are feeling unwell;

No additional guest is allowed;

Wearing a mask is required upon arrival and during the entire procedure;

Wash hands upon arrival;

Limit conversation during the procedure.

By signing below, I agree to each above statement and release the venue and its employees from any and all liability for the unintentional exposure or harm due to Covid-19 and other communicable conditions.

Date(Required)

Client Name (Printed)(Required)

Our Policy:

Please reach out with questions and concerns.

Client Signature(Required)

PHOTO & VIDEO RELEASE FORM

I(Required)

, hereby grant and authorize

authorize(Required)

(Esthetican) & iModel Beauty Bar the right to take, edit, alter, copy, exhibit, publish, distribute and make use of any and all pictures, video, and/ or audio taken of me to be used in and/ or for any lawful promotional materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, press kits, websites, social media sites and other print or digital communications without payment or any other consideration.

This authorization extends to all languages, media, formats, and markets now known and later discovered.

I will be consulted about the use of the photograph and/ or video recording for any purpose other than those listed below:

promotional materials;
printed and/ or digital advertisements;
educational presentations or courses;
informational presentations;
online educational courses;
educational videos;
social media posts.

There is no time limit on the validity of this release nor is there any geographic limitation on where these materials may be distributed.

By signing this form I acknowledge that I have completely read and fully understand the above release and agree to be bound thereby. I hereby release any and all claims against any person or organization utilizing this material for educational purposes.

Do you agree to be photographed or video'd during your service?(Required)

Decline

Date(Required)

Client Name (Printed)(Required)

Client Signature(Required)

iModel Intake Form

COVID-19 LIABILITY RELEASE WAIVER

PHOTO & VIDEO RELEASE FORM

Book Service

Contact info

Address:

141 Mangum St SW, Suite 300

Atlanta, GA, 30313

Phone:

470-753-9303

Email:

contact@iModelBeautyBar.com

Opentime:

Tues - Sat 10:00am - 5:00.pm

Shopping

Infomation

Payment methods

We accept online payments via credit card, debit card, and Sezzle. Additionally, we accept in-store payments.

© Copyright 2021 iModel Beauty Bar

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