Please Submit Online. 

Fill out all boxes with the asterisk symbol (*) and check () all the APPROPRIATE boxes to complete submission.

All other boxes: Only answer questions that apply to you.

Name *
Phone *
Referred by:
Any cold sores breakouts today? (Herpes Simplex I)
Are you Pregnant?
If Yes:
Are you lactating?
Acne problems?
Are you under a dermatologists or a doctor’s care?
Have you ever had any cosmetic surgery?
Do you currently use any of the following medications or products with any of the following ingredients?
When was the last time you had any of the following treatments?
Contact lenses?
Do you sunbathe?
Please note, do not expose skin to the sun or tanning beds for at least 48 hours after any waxing service or advanced facial treatments. Please use SPF products, 30 minutes before sun exposure to prevent discoloration. *
Any skin reactions after wax or facial treatments?
Please check any that apply to you:
WAX HAUS AND SKIN POLICIES: • We do not wax anyone who’s on Accutane, Retin-A or other prescriptions that exfoliate or thins the skin • We cannot perform any services to clients with current cold sore breakouts, open wounds or sores • You understand that any wax or skin service can trigger a cold sore outbreak • Prices are subject to change without notice (services and products). No cash refunds on any gift certificates. The promotional value of any series sold expire after 3 months of inactivity (last visit at the spa). Unused monies/balance can be applied towards future services or products. No cash refunds. Please use them accordingly • Defective products must be returned within 10 days to receive credit or exchange only. No cash refunds • Information in this form is completely private and confidential. *
CANCELLATION AGREEMENT: Please notify us 8 hours in advance if you need to reschedule, modify or cancel your appointment with a call/text or an email. First time late cancellation/modification, late arrival or no-show: A credit card will be required to schedule future appointments. Any vouchers or certificates associated with that appointment will be considered as redeemed right away. Your credit card will be charged a 50% fee right away of all services scheduled that day. If you have prepaid waxing series, one of them will be considered as redeemed right away. Second time: Your credit card will be charged a fee equal to 100% of all the services scheduled. If you have prepaid waxing series, one of them will be redeemed right away. Any vouchers, gift cards, certificates or special online offers associated with that appointment will be considered as redeemed. I (the client who submits this form) understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I release D.Perivolaris and Wax Haus and Skin from liability and assume full responsibility thereof. I fully understand all the above questions and policies and I authorize treatments. By submitting this form your email will be added to our private list, for our spa updates, promotions, newsletters and reminders. We do not use your email for any other reason. If you don't want to receive emails from us, you can unsubscribe instantly from our list with the link provided there.