Brown Shugar Day Spa: Mobile Day Spa Shop::Client Forms::Waxing Consultation Form

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WAXING CONSULTATION FORM:

please fill out form completely. *Required

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CLIENT INFORMATION

FIRST NAME :

LAST NAME :

ADDRESS :

CITY :

STATE:

ZIP CODE :

PHONE:

ALTERNATIVE PHONE:

EMAIL ADDRESS:

REFERRED BY:

HEALTH INFORMATION

Do you have sensitive skin? Select One: yes no

How often do you have waxing done?

Are you taking Accutane? Select One: yes no

Are you using Retin A? Select One: yes no

Do you have any moles or abrasions in the area to be waxed? Select One: yes no

Do you have vericose veins in the area to be waxed? Select One: yes no

Do you have Diabetes? Select One: yes no

Do you use a loofa when you bathe? Select One: yes no

Is your pain threshold Select One: Low Medium High?

SERVICES INTERESTED IN

Please check services you are interested in receiving.

I understand that any information provided by the Esthetician is for educational purposes ONLY and not diagnostically prescribed in nature. I understand that the information herein is to aid the esthetician in giving better service and is completely confidential.

By submitting this form, I understand and agree to the above.

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