WAXING INTAKE FORM

Client Information
Client Information
How did you hear about Wine & Unwind Day Spa?!
Client Information
Have you ever received a professional waxing session?
If yes, How recently and what area?
Did you have any adverse reactions, including ingrown hairs?
If yes, please explain.
Please list all medications (over-the-counter and prescribed) and supplements that you are currently taking:
Please list all allergies or sensitivities, including smells:
Do you have or have you recently been in contact with any contagious illnesses or infections, including skin conditions:
If yes, please explain.
Have you ingested any alcohol or illegal substances in the last 24 hours?
FEMALES: Are you currently pregnant?
Do you have diabetes?
Do you have cancer?
Are you using or have you used any glycolic, salicylic, Retinol, Retin-A, Accutane, or any doctor prescribed acne/anti- aging creams, gels, or medications (oral or topical)?
If yes, please describe:
Do you use a tanning bed or tan in the sun on a regular basis?

If you have any of the following occurring today, please comment; Broken bones  Cold/flu/fever  Cold Sores/Herpes lesions Cuts/bruises/burns  Inflammation  Menstruation  Skin rash  Sunburn  Warts
FEMALES: What is your menstrual cycle due date?
Please list any medical illnesses/conditions for which you are currently receiving treatment:
Please list all products used regularly on the area to be treated today:
Choose your beverage of choice for all services $40 or more. Must be 21 years of age or older for alcoholic beverages, must have ID.




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