Style That Ash Waxing Intake Form
Please provide your personal information below. Thank you!
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AM/PM Option
Full Name
*
Please type first and last name.
D.O.B. (MM/DD/YYYY)
*
Phone
*
Email Address
*
example@example.com
How did you hear about us?
Skin Intake Information
What type of skin do you have?
Normal
Oily
Dry
Combination
Have you been under the care of a dermatologist within the past year?
*
YES
NO
If yes, please explain...
What areas of concern do you have regarding your skin?
Ingrown Hair
Blackheads/Whiteheads
Acne Prone Skin
Hyperpigmentation
Dry Skin
Rosacea
Sun Damage
Broken Skin
Redness/Ruddiness
Dehydrated
Other
Have you ever had an allergic reaction to any of the following?
Cosmetics
Witch Hazel
Coconut
Sunscreen
Fragrance
Latex
Oils
Other
Do you currently or have you used in the last 3 months Retin-A, Renova, AHA's, or Retinol/Vitamin A derivative products?
*
YES
NO
If yes, please describe...
Have you received Botox, Restylane, or Collagen injections in the last 6 months?
*
YES
NO
If yes, please specify...
Client Signature
*
Submit
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