One Woman Spa Wax Questionnaire Template

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One Woman Spa Wax Questionnaire
Name:____________________________________________!
Date:___________
Address:__________________________________City_______________Zip________
Best Phone Number to Reach You: (____)____-________
Best way to Remind your of your Appointment: (circle one) Call! Text!
Email
Email:_________________________________________________________________
How Did you Hear about us?
Internet
Ad
Coupon
Referral (Name:________________)
What Part of the body are we waxing today? __________________________________
When did you last shave/Trim? __________________________!
Have you ever been waxed before? YES / NO When?__________________________
Do you have any tendencies towards:
Ingrown Hair YES /NO!
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Hyper-pigmentation YES / NO!
Eczema YES / NO
Break Outs YES / NO!
!
Bruising YES / NO!
!
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Psoriasis YES / NO
Bumps YES / NO! !
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Scarring YES / NO
Are you Currently Using/Taking:
Isotretinoin/Accutane YES / NO!
!
Resorcinol YES / NO!
Indoor Tanning YES / NO! !
Retin-A YES / NO!
!
Glycolic Acid YES / NO
Self Tanners YES / NO!
Alpha-hydroxy Acid YES / NO!
Scrubs or Peels YES / NO
Medical Data:
Herpes Virus YES / NO!
!
Staph/MRSA YES / NO!
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Allergies YES / NO
List:__________________________________________________________________
Other information:_______________________________________________________
Initial the following:
Waxing may cause: Bruises, scabs, scarring, redness, hyper-pigmentation, pimples, or a flare up of any of the above
mentioned conditions/responses. Waxing of soft tissue may cause the skin to tear, resulting in the need for stitches.
While this RARELY happens, it is most likely to occur in Brazilian waxes. ______________
I understand that if I have Herpes or Staph/MRSA, I may experience an outbreak after my waxing service. The
professional has explained to me the best way to minimize or prevent an outbreak when waxing regularly.
_______________
I understand that I may carry the Herpes and/or Staph/MRSA without any physical symptoms or a medical diagnosis.
I also understand that the waxing service does not allow the opportunity to contract these conditions from my
technician. _____________
I understand all of the above mentioned reactions. I also understand if I change my skin care routine or medications, I
MUST inform my professional Prior to any future services. _____________
I understand that I must be showered and prepared for my service. _________________
I understand that if I miss or cancel my appointment without 24 hours notice, I will be charged $25 or HALF of the
service fee, whichever is Greater. ___________
_____________________________________________________________________________________________
Signature!
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Date

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