Download Please fill in and send back as an attachment to info@basicsalon

www.basicsalon.com
Please fill in and send back as an attachment to [email protected]
If you are having problems viewing this form please contact us as we will send you a copy in a different format.
Customer Registration Form
This is a confidential form and we give you assurance of your personal details upon the Data protection Act. Your
personal information will not be shared with any third parties. We will seek your approval for any necessary use of
your information.
Will have after registration
Voters registration number :
We are hereby, committed to provide you with excellent service. Please fill in the blanks or mark the appropriate
answer as accurate as you can. If you are unsure of the question, please do not hesitate to ask reception who will
be happy to help.
Title: Miss/Ms/Mrs/Mr/Dr/
First name:
Surname:
Occupation:
Landline number:
Date of birth:
Mobile:
Email:
Please mark an X on your answers:
What is your interest with us:
Hair
Skin
Body
Nails
Would you like to receive via email on our pricelist and inform you on any promotional treatments and offers:
Yes
No
Please note that you can view our pricing and promotional treatment on our website: www.basicsalon.com
Please mark an X or fill any of the following that applies to you:
Epilepsy
Impetigo (bacterial)
Spastic conditions
Severe varicose veins
Infections
Recent scar tissue
Diabetes
Cancer: Skin or others
Contagious disease
High/low blood pressure
Psoriasis
Contagious disease
Eczema
Tinea vesicular (Fungal infection)
Thrombosis
Malignant melanoma
Verruca (viral)
Pacemakers/heart problems
Severe skin conditions diseases or disorders
Undergoing medical treatment
Scabies/ Infectious contagious diseases
Systemic medical conditions
Dysfunction of the nervous system
Carrier of HIV,AIDS, Hepatitis
Cardio vascular problems ie. Heart disease
Undiagnosed lumps, bumps, swellings
Others:
Above are Contra Indications and if you have any of these, you will require medical approval/ referral before any
skin treatments or body electro-treatments.
1
This is the copyright of basicsalon ltd, registration no. 06102738
www.basicsalon.com
Allergic reactions to products
Migraines:
Hyper sensitive skin
Under influence of alcohol or drugs
Pregnant, months
Recent operation, (specify where):
Bruising on areas, (specify where):
Unexplained bodily pain, (specify where):
Pigmentation disorder :
Sunburn/ heartburn:
Metal pins or plates implant, (Specify where)
Recent fractures/sprain, (specify where):
High anxiety
Dermatitis, (Specify where):
Botox, (Specify where):
Excessive metal dental work
Systemic medical condition:
Inflammation on the treated area:
Severe menstruation pain:
Others:
Any of the above can prevent and /or restrict to treatments on those areas. Please inform our practitioner before
commencement of any treatment.
Is there anything that you think our practitioners needs to know prior to your treatments to avoid any bad
reaction which we will not be responsible?
Please mark with an X which of these you have done or had a test patch:
Yes
No
Yes
Date:
Hair tint
Did you have a reaction
Date:
Hair Perm
Did you have a reaction
Date:
Hair lightening
Did you have a reaction
Date:
Hair Straightening
Did you have a reaction
Date:
Eyelash/brow tint
Did you have a reaction
Date:
Eyelash perm
Did you have a reaction
No
Other possible contra-action:
It is mandatory that the above testes should be done 24hr prior to relate treatments request. Please note that any
reaction on the above may restrict the treatment on you.
Once you are registered with us, you will be given your customer number which would be needed every
time when you use our services. Some questions may be asked when you visit for verification. Please do
update us on any changes to your medical condition.
Please read our policy, terms and conditions.
Our Salon policy:
http://www.basicsalon.com/policies.html
Our Terms and conditions: http://www.basicsalon.com/termsandconditions.html
Do you agree to our terms and conditions?
Please sign: ………………………………………
Yes No
Date:………………………….
Thank you for registering with basicsalon – hair & beauty workshop
2
This is the copyright of basicsalon ltd, registration no. 06102738