Given Name
Last Name
Address
City
Postal Code
E-mail
Phone
Do you suffer from, or have you ever had:
1. Diabetes
YesNo
2. Phlebitis
Do you have any allergies?
Do you use Accutane?
Do you use Retin-A?
Are you using any Glycolic Acid/AHA-based skin care products?
I have been informed of possible redness, blistering or peeling as a result of waxing. I will not hold Sarita’s Beaute Spa or its operators responsible for any damage caused to my person or as a result of allowing the waxing procedure to be performed on me.
Name
Date
Normal
Sensitive
Hypersensitive
PREFFERED WAX TYPE:
USUAL AREA WAXED:
Full Leg with Bikini
Upper ½ Leg
Lower ½ Leg
Bikini
Underarm
Full Arm
Forearm
Brow
Chin
Lip
Chest
Back
Your name
Your email
Subject
Your message (optional)
