Waxing & Facials

Intake Questionnaire

First Name:

Last Name:

Email:

Address:

Phone:

Date of Birth:

How did you hear about us?

Are you currently taking any medications?

Are there any other medical of health concerns?

Are you currently using or taking any of the following?

Accutane Resorcinol Renova Retin-A Microdermabrasion Alpha Hydroxy Acid/Glycolic/Lactic Acid Exfoliating Scrubs/Peels(any)

Do you have any tendencies towards any of the following?

Ingrown Hair Cold Sores/Herpes Bruising Hyperpigmentation Bumps Sensitivity

Additional details:

*It is my choice to receive treatment from Willis Day Spa. I have read and answered to the best of my knowledge the above information and therefore will in now way hold Willis Day Spa liable for any potential reactions that may result from treatment. I agree to keep the practitioner up to date concerning my medical profile and understand that there will be no liability on the practitioners part should I forget to do so.

Signature:

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