Electronic Waxing Form - Rosewater Spa & Wellness

Name*

Phone*

Email*

Birthday*

Mailing Address*

City*

State*

Zip*

Emergency Contact*

Emergency Contact Phone Number*

Have you used and Alpha Hydroxy Acid (AHA) or glycolic products in the past 48-72 hours?*

Yes No

Are you using Retin-A/Retinol/Acutane (oral form of Retin-A)?*

Yes No

Are you currently using any blood thinning medications?*

Yes No

Are you exposed for prolonged periods of time to the sun on a daily basis or are you considering spending more time in the sun soon?*

Yes No

Do you use the tanning bed?*

Yes No

Are you a diabetic?*

Yes No

Do you take/have hormonal contraceptives or implants?*

Yes No N/A

Are you taking hormone replacement medication?*

Yes No N/A

Are you pregnant or trying to become pregnant?*

Yes No N/A

Are you nursing?*

Yes No N/A

I understand that waxing does have certain side effects such as skin removal, redness, swelling, tenderness, etc. The goal of waxing, as in any cosmetic procedure, is improvement not perfection. I understand that my results may not be perfect. In the case of waxing, the number of treatments necessary will vary among individuals and the areas being treated. I understand the practice of aesthetics is not an exact science and that no specific guarantees can or have been made concerning the expected results. *

I have read all of the above

*First Name
*Last Name
*Email
*Mobile Phone	( ) -