Wax Consultation

Body & Facial Wax Consultation
Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Birthday (MM/DD)*
Are you at least 18 years old?*
How did you hear about us?
Have you been waxed before?
Do you have a type of wax you prefer us to use?
Are you pregnant or nursing?*
Are you currently taking any medications?*
Please list any know allergies or write NONE*
Are you currently using any products/taking any medications that contain*

TazoracRetinol/Retin A/ RenovaDifferinEpiduoOther prescription product for acne/agingSteriod creamSteroid medication such as prednisoneOther medications for acneNone
When was your last skin resurfacing treatment such as microdermabrasion or chemical peels or write none?*
Have you had any dermal fillers, botox or other injectables in the past 2 weeks?*
Have you ever had an adverse reaction to a waxing service?*

skin liftingskin burnallergic reactionsensitivityOtherNone
What is your current skincare routine (if having a facial wax)?
Consent for treatment:

I give permission for Miss Melissa, LLC, dba The Nail and Wax Room, (and their associates) to treat me today. I have disclosed any allergies and current medical conditions. I release any liabilities that may arise during or after as a consequense of my treatment. If my treatments are ongoing, I will disclose any new allergies, medical conditions or medications at the time of my service.
Appointment Date*

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Date
Today's Date

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Date
Signature*

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Body & Facial Wax Consultation