Aesthetics New Customer Registration Form

Client Details

Title: *

If Other, please specify:

First Name: *

Middle Name(s):

Last Name: *

Address: *

Postal / Zip Code: *

Email: *

Phone (Home):

Phone (Cell/Mobile): *

Date of Birth: *

How did you hear about us? *

If Other, please specify:

How would you like us to contact you? *

Phone Text Email Mail

Emergency Contact Details

Emergency Contact Name: *

Emergency Contact Relationship: *

Emergency Contact Phone: *

Photography

Please tick the relevant boxes if you give us permission to take photographs of your treatment(s) / service(s)

I give permission for my photograph(s) to be used within the salon for display / educational purposes I give permission for my photograph(s) to be used within other printed publications I give permission for my photograph(s) to be used on the salon's social media pages / website

Client Signature: *

Tap or click on the signature above to sign