Printed name       Date

Birth Date       Website

Contact Numbers (please check () preferred number for calls, messages and reminders:

Cell       Landline       Email

Mailing Address:

City:       State:       Zip Code:       Country:

Please check () how you were referred to LAURA LEE HAIR MAKEUP IMAGE:

Website      Personal referral      Media ad      Other

GOOD FAITH HOLD HARMLESS AGREEMENT

Voluntary answers to the following questions aids in determining the appropriateness of services and products used during your appointment. By signing below you acknowledge LAURA LEE FRY is a licensed cosmetologist conducting business as an independent contractor, carries professional liability insurance, and thus practices certain protocols and procedures. Parent/guardian must sign in person at time of services for minors.

Are you currently under the care of a Licensed Health Professional?  Yes    No

List 3 known allergies or sensitivities to food:

  1.      2.      3.

List 3 known allergies or sensitivities to nutritional supplements:

  1.      2.      3.

List 3 known allergies or sensitivities to medications:

  1.      2.      3.

List 3 known allergies or sensitivities to cosmetics:

  1.      2.      3.

Please initial the following statements:
I am voluntarily providing confidential information regarding health, allergies, and sensitivities.
I understand Laura Lee may refuse services based on information provided on this form.

Signature ___________________________________________________________  Date _______________

Minor's signature _____________________________________________________  Date _______________

Parent/guardian printed name & signatures _____________________________________________________

____________________________________________________________________  Date _______________

Laura Lee Fry signature ________________________________________________  Date _______________

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