Name
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First Name
Last Name
What are your pronouns?
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Email Address
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City & Zip-code
Phone
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(###)
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Date of Birth
MM
DD
YYYY
What do you value the most? A: Stability, Structure, Planning, Rules. B: Freedom, Flexibility, Excitement. C: Relationships, Teamwork, Community. D: Learning, Logic, Research, Accuracy.
Have you ever experienced cold sores on lips or face (Herpes Simplex I)?
Please note: If you have a current -OR- had a recent cold sore, we cannot perform ANY facial waxing or facial treatments, until the breakout is completely healed and gone. If you develop one on the day of your appointment, notify us as soon as possible so we can reschedule your service.
Are you Pregnant?
Acne problems?
If yes, where?
Are you currently taking blood thinners or regularly taking aspirin? If yes, please provide details below. If no, please type "No".
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Please note: These medications can make the skin more fragile, increasing the risk of lifting, bruising, and damage. They are contraindicated for waxing and certain facial treatments. Please contact me for a consultation before booking.
Please list any prescribed medications (from a doctor) you are currently using, including: Antibiotics (oral or topical), Acne treatments (topical creams, oral medications, or antibiotics), Anti-aging prescriptions (Retin-A, tretinoin, or other medical-grade treatments). Include the brand name, prescription name, and strength of the medication.
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If none, please type "None"
Are you under a dermatologist's or a doctor’s care?
If yes, what is the reason for treatments?
Are you currently using any medications or skincare products that contain any of the following ingredients?
If none, please check the "None" box.
If yes, how long have you been using these products, and how often do you apply them? Please provide the medical name and strength. If you have used any of these in the past, when was your last treatment? Use the space below to provide details:
(Only if they are prescribed medications, not OTC products)
After any waxing service or advanced facial treatments and for the next 48 hours, please use SPF products (30 minutes before sun exposure) to prevent discoloration, avoid skin sensitivities and burns.
Have you been waxed before? If yes, did you had any skin reactions after? Please describe below:
Do you have any skin concerns or current issues with ingrown hairs?
Please check any that apply to you:
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If none, check the "None" box.
Use the space below to provide any additional details or clarifications related to the questions in this form, if needed.
Spa Policies/Liability/Disclosures:
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We do not perform waxing on clients using Accutane, Retin-A, or other prescriptions that thin or exfoliate the skin. We will review this form and additional questions may be asked prior to treatment. Services cannot be performed on areas with cold sores, open wounds, or active breakouts, and you acknowledge that facial or waxing treatments may trigger cold sores. We kindly ask that you provide at least 48 hours’ notice for any cancellations, reschedules, or appointment changes. Appointment changes made with less than 24 hours’ notice may incur a 50% cancellation fee and/or require full prepayment for future bookings. We do not offer cash or credit card refunds. Spa credit may be issued when applicable and is valid for products or services.
By submitting this form, you confirm that all information provided is accurate and understand that withholding information may result in adverse reactions. You release D. Perivolaris and Wax Haus & Skin from liability and give consent to receive treatment. All information submitted is kept private and confidential.
Your email may be added to our mailing list for spa updates, promotions, and reminders—you may unsubscribe at any time.
Please type your full name below to confirm and submit this form.
