Contact Information

First name

Last name

Email

Phone

Address

Birthday

Dzień

Miesiąc

Rok

I agree to receive occasional emails with special offers, appointment reminders, and updates from AuraLuxe. I understand I can unsubscribe at any time.

By ticking this box, you consent to being added to our mailing list. Your information will be stored securely and will not be shared with third parties.

Medical History / Contraindications

If yes to any of the above, please provide more information:

Medications and Allergies

Are you taking any medications or have allergies we should be aware of? (E.g. aspirin, antibiotics, latex, nuts, etc.)

Treatment History

Have you had this treatment before? Options: Yes / No

Yes

No

I have not been to AuraLuxe Salon / American Beauty Salon before.

Date Picker (if Yes): When was your last treatment?

Dzień

Miesiąc

Rok

🟣 Previous Treatment History

(For Existing Clients)

If you've been treated at AuraLuxe before, help us keep your file up to date.

Add your text

If other, please specify:

Were there any issues or reactions with previous treatments?

Patch Test Confirmation& Consent

Have you had a patch test for this treatment in our salon?

Yes, within the last 3 months

Yes, more than 6 months ago (new patch test required)

Write Date of Patch test (48 hours prior to treatment)

Dzień

Miesiąc

Rok

Did you experience any reaction after your patch test?

No reaction

Mild redness/itchiness that resolved

Swelling, rash, blistering, or severe discomfort (treatment will not proceed)

I confirm that:

I have completed a patch test at least 48 hours before my appointment.

I have disclosed all relevant medical history.

I understand that results may vary and there is a small risk of reaction.

I give consent to proceed with the treatment.

Signature

Client Signature

Wybrano tryb rysowania. Rysowanie wymaga myszy lub touchpada. Aby włączyć klawiaturę, wybierz Tekst lub Prześlij.

Emergency Contact

Emergency Contact Name

Phone

Treatment Goals or Notes

What are your main concerns or goals for today’s treatment? (E.g. brow shaping, nail strengthening, clearing skin, relaxation, etc.)

Client Declaration

Please confirm:

I have answered all questions truthfully

I will follow all aftercare instructions given

I understand the salon's refund and rescheduling policy

Signature

Final Signature to Confirm Submission

Wybrano tryb rysowania. Rysowanie wymaga myszy lub touchpada. Aby włączyć klawiaturę, wybierz Tekst lub Prześlij.