Name
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First Name
Last Name
Email
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Phone
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(###)
###
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Date of Birth
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Emergency Contact: Name, Phone Number, Relationship to Client
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Have you ever been waxed?
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If yes, please describe what type of waxing was performed?
Have you ever had a bad reaction to a waxing service before?
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If yes, please describe in detail.
Do you currently, or have you in the past taken Accutane?
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Do you currently, or have you in the past taken Retin-A?
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Do you currently, or have you in the past taken Renova?
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Do you currently, or have you in the past taken Adapalene Hydroxy?
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Do you have any known allergies?
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If yes, please indicate all dietary, medical, and topical allergies you have.
Do you take any medications?
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If yes, which medications do you take?
Are you currently taking birth control?
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If yes, which type of birth control.
Are you currently pregnant or breastfeeding?
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If pregnant, how far along are you? If breastfeeding, when did you give birth?
Are you currently or have you in the past two weeks past experienced any cold, flu, or other illness symptoms?
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If yes, please describe.
By submitting this form, I understand, have read, and have completed the above intake form truthfully and to the best of my ability. I agree that this document constitutes full disclosure and by withholding any information about my skin and/or health may cause contraindications and/or irritation to my skin during the treatment. The treatment I receive is voluntary and I release Girl on the Go Wellness Spa and all technicians working on me from liability and assume full responsibility thereof.
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