THE DAY SPA

The Day Spa Waxing Intake Form

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Date Of Appointment (Month/Date/Year)

Full Name

Date of Birth (Month/Date/Year)

Address

City

State

Zip

Email

Primary

Secondary

Pls select your preferred method of communication for future appointment confirmation:

What body part(s) are being waxed today?

When did you last shave body part(s)?

How often to you typically shave body part(s)?

Have this body part(s) ever been wax before?

Medical Record
Please check any of the following that apply to you:

Varicose Veins

Epilepsy

Psoriasis

Hypersensitivity

Poor Circulation

Cold Sores

Skin Disease

Moles

Warts

Diabetes

Sunburn

Recent Scars

Pregnancy

Any known allergies?

Please check all products you have used in past and /or are currently using:

Retin A/Retinol

Accutane

Renova

Differin

Alpha Hydroxy Acids

Hydrocortisone

Acne Medication

Beta Hydro Acids

Peels/Scrub of any

Salicylic Acid

Glycolic Acid

Steroids

Do you have tendencies to:

Ingrown Hair

Scarring

Bruising

Bumps

Hyperpigmentation

Please list any other illness/condition you are currently being treated for by a medical professional:

Have you ever had any problems with waxing in the past?

Do you use a tanning bed?

Are you currently taking any medications? If so, please list all (including over the counter drugs/herbal supplements):

*Please note that waxing can have certain side effects including but not limited to: redness, swelling, bruising, irritation, ingrown hair, hyperpigmentation, allergic reaction etc.

I give permission to my therapist to perform the waxing procedure we have discussed and will hold her and her staff harmless from any liability that may result from this treatment. I also understand that use of any of the above products increases the possibility of reaction and will advise my esthetician if there are any changes to my health history. I am willing to follow recommendations made by my esthetician for a home care regimen that can minimize or eliminate possible negative reactions. I hereby confirm that by signing this form I am accepting responsibility for any reaction caused from a waxing service if I neglect to inform The Day Spa of the above information.

Electronic Aknowledgement

Date Today (Month/Date/Year)

The Day Spa

A full spa experience to encourage self care and stress management. The Day Spa proudly services the Greater Green Bay area as a premier salon and spa. The nurturing sanctuary and tempting choices of over 100 treatments designed to reinvigorate the mind, body and soul. It's time... For you.

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600 N. 10th St. De Pere, WI 54115
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Phone: (920)-339-5250
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