Name

First Name

Last Name

What are your pronouns?

She/Her

He/Him

They/Them

Prefer not to say

Email Address

City & Zip-code

Phone

(###)

###

####

Date of Birth

YYYY

What do you value the most? A: Stability, Structure, Planning, Rules. B: Freedom, Flexibility, Excitement. C: Relationships, Teamwork, Community. D: Learning, Logic, Research, Accuracy.

How did you hear about Wax Haus and Skin?

Referred by:

List any known skin allergies or sensitivities to products or ingredients:

Have you ever had cold sores (Herpes Simplex I) on your lips or face?

Important: If you currently have or recently had a cold sore, we cannot perform any facial waxing or treatments until the area is completely healed. If a cold sore appears on the day of your appointment, please contact us immediately to reschedule.

Yes

I never get cold sores

I recently had one but it's completely healed

Are you Pregnant?

Yes

Not yet, I'm trying

Are you currently taking, or have you recently taken, blood thinners or aspirin?

Important: If none, type NONE. If yes, please contact us for a consultation before booking. Blood thinners and aspirin are an important contraindication for waxing and certain facial treatments. These medications can make the skin more fragile and increase the risk of lifting, bruising, and damage.

List any prescribed medications you are currently using, including: Oral or topical antibiotics, Accutane, Acne treatments (topical creams, oral medications, or antibiotics), Anti-aging prescriptions (Retin-A, tretinoin, or similar medical-grade treatments).

Please include the brand name, prescription name, and strength. If none, please type NONE.

Are you currently under a dermatologist's or doctor’s care?

If yes, please explain the reason for your treatment:

After any waxing or facial treatment, SPF must be applied daily for at least 48 hours. We recommend applying sunscreen at least 30 minutes before sun exposure to help prevent discoloration, sensitivity, and burns.

I understand and assume full responsibility for following aftercare instructions.

Have you been waxed before? If yes, did you experience any skin reactions?

Please describe:

Please describe any current skin concerns, including issues with ingrown hairs.

Use this space to explain:

Use the space below to provide any additional details or clarifications related to the questions in this form, if needed.

Spa Policies/Liability/Disclosures:

At Wax Haus & Skin, your safety and experience are our priority. We cannot perform waxing on clients using Accutane, Retin-A, or other prescriptions that thin the skin. Services also cannot be performed on areas with cold sores, open wounds, or active breakouts, and waxing or facials may occasionally trigger cold sores. Please give at least 48 hours’ notice for any changes; appointments changed with less than 24 hours' notice may require full prepayment for future bookings. By submitting this form, you confirm that all information is accurate, release D. Perivolaris and Wax Haus & Skin from liability, and consent to treatment. Your information remains private. You may receive occasional spa updates and can unsubscribe anytime. Please type your full name below to confirm and submit:

Thank you for choosing Wax Haus and Skin. Looking forward to meeting you!

~Dee

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