New Patients

Welcome to Agnes Beauty and Wellness

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We strive to provide the best possible experience for our clients. Please fill out the information below so that we may best serve your needs.

Agnes Beauty & Wellness upholds CDC standards of sanitation practices. We do not accept clients who show symptoms of sickness. We are not liable for any loss related to contacting covid-19.

Intake Form

Do You Have Children?
Have you had Aromatherapy before?
Have you had Massages before?
Have you had Sculptural Face Lifting before?
Do you Take Blood Thinners?
Do any of the following symptoms apply to you?
Check any of the following you experience more than once a week
Please Describe your skin - Check any that apply
What is your general Stress level?
How manageable is your level of stress?
Describe your activity level
Do you suffer from any of the following
Are you comfortable with having intraoral procedure? (applies when receiving a face sculpting buccal massage, practioner works inside the oral cavity wearing sterile gloves.)

If at any time you become pregnant you must advise us immediately.

Started Menopause?
Finished Menopause?

By submitting this form you acknowledge reading and accept the following;

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I have stated all my known conditions and have answered all questions honestly. I take it upon myself to keep the Therapist updated on my health.

 

I understand that the Therapist does not diagnose, prevent or treat illness, disease or any other physical or mental conditions. 

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I understand that this treatment is not a substitute for medical treatments and/or diagnosis, and it is recommended that I see a qualified professional for any physical or mental condition that I may have. 

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I understand this treatment is not a substitute for medical care. 

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The Therapist has provided and explained the safety issues surrounding my treatment plan. I have had the opportunity to ask any questions. 

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I understand the following: 

• I am not being advised to take any essential oil products internally 

• I must keep all essential oil products out of the reach of children 

• Essential oils could be poisonous if swallowed 

• Essential oils must be stored in a cool, dark place 

• Essential oils may irritate the skin if not stored or used properly 

• Essential Oils must not be used with animals 

• Essential Oils must not be used on the skin of babies or children under 1 years old 

• Essential Oils must be used with extreme caution for children under 5 years old. 

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I hold Agnes Beauty and Wellness harmless for any injuries or negative effects I may experience as a result of having the treatments done on me during the course of my treatment plan, or using the products I receive during this consultation. 

Your form has been received! Thank you.

COVID-19 Liability Release Form

Please take a moment to sign this online waiver. This form is required for all visits to Agnes Beauty & Wellness. It is also available in person.

Sign Waiver