Well of Life Center for Holistic Healthcare

Oncology Esthetic Care Intake Form

New Client Appointment Checklist


Complete and submit form below

Please arrive at least 15 minutes early for your first appointment.

These guidelines are in place for your protection and ours, as we strive to serve you to the best of our ability. Please contact our Client Advocate if you have any questions or need additional information.

Please understand the importance of keeping your appointments. We do have a 48 hour new client/24 hour regular client appointment cancellation policy that is strictly enforced.

Your answers to the questions on this form are essential for a safe, effective session. Please take some time to answer in detail, and have this paperwork completed prior to the start of your appointment.

Oncology Facial Contraindications

May NOT be done if you have any of the following:

Presence of infection: edema, pus
Pain: sensitive to touch
Open wounds: wounds that are not healing, susceptible to infection
Rash: vesicles, inflammation, pruritus
Moist desquamation: skin peeling with the presence of infection
Chemo-induced acne: acne lesions produced by systemic chemotherapy
Hypersensitivity: extremely sensitive skin, contact dermatitis

New Client Form


In Case of Emergency, please contact:

Health & History Questionnaire

Skin Care History Questionnaire

General Signs & Symptoms

Check “yes” or “no” and add comments if you have or have had any of the following:

Other Medical Conditions

Check “yes” or “no” and add comments if you have or have had any of the following:
Important note: It is my choice to receive esthetic care. I understand that the information given above is strictly confidential and will be used for no other purpose than to assist the esthetician in providing suitable service(s) which would take into consideration my specific requirements. I also understand that failure to disclose all my known medical conditions could result in injury and/or illness. I hereby release Well of Life Center for Natural Health, LLC from any claims resulting in such. Any information provided to me by the esthetician is for general purposes only and is not intended for any medical or therapeutic purposes.
Please click HERE to read our Agreement and Release of Liability form. Then, sign below. By signing, you are acknowledging that you have read and accept the terms and conditions of the Agreement and Release of Liability.

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