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Please call to make an appointment before fill out the application.
CALI SPA WAXING CLIENT INFORMATION
Name: *
Phone: *
Address: *
City: *
State: *
Zip: *
Email: *
Occupation:
Age:
Referred by:
Date of Consultation:
All Clients
1.
Are you using
Retin A,
Accutane,
Glycolic Acid,
Other skin thinning substance?
2.
Have you used any of the above in the last 6 months?
3.
Have you had a Chemical Peel or Surgical Procedure? What type
4.
How long ago did you have your peel or procedure?
5.
Do you have cancer or have had cencer?
YES
NO
How long ago?
6.
Are you on chemo?
YES
NO
7.
Do you have any open wounds, cuts, herpes, simplex in the area to be waxed?
YES
NO
8.
If yes, please explain which
9.
Are you diabetic?
YES
NO
9.
Are you talking any steroids?
YES
NO
Female Clients Only
1.
Are you pregnant or trying to become pregnant?
YES
NO
2.
Are you currently having or due for your menstrual period?
YES
NO
I confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information thay may be relevant to my waxing.
Client Signature
Date
Client Signature
Date
Client Signature
Date
Client Signature
Date
Client Signature
Date
Client Signature
Date
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