Facial

Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number*

Area CodePhone Number
Email*
example@example.com
How did you hear about me Wax and Beauty?
Have you had a facial before?*

YESNO
What is your skincare goal?
What are your specific skincare concerns?

Dry Flaky SkinBreakoutsWrinklesBlackheadsAcne*Loss of FirmnessClogged PoresSkin TextureLarge PoresHyper-Pigmentation / Uneven Skin ToneRednessSkin SensitivityRosaceaOily SkinMiliaFine LinesOther
Give us an idea of what you typically use on your skin daily?*

SoapCleanserTonerSerumMaskExfoliant (physical or chemical)Eye CreamMoisturizerSPFVitamin A (retinol)I don't use anything
Any known allergies?*

AspirinLatexFruitsShellfishLidocaneFragrance/Essential oilsTree NutsDairySunscreenPollenNoneOther
Have you ever been diagnosed with eczema, psoriasis or rosacea on the face?

YESNO
Are you currently using any products that contain:

AHA (glycolic acid, lactic acid, etc.)BHA (salicylic acid)Vitamin A derivative (retinol/retonids)Exfoliating scrubsPrescription TopicalsNO or UNSURE
Do you currently have any rashes, itching or underlying redness on your face?
Please list medications or supplements you are currently taking.
This will help me determine if it's a contraindication for certain modality.
Have you ever received chemical peels or laser services treatments?

YES, within the last monthYES, within the last 2-3 monthsNO
Have you had botox in the past 7 days?

YesNo
Have you had fillers in the past 14 days?

YesNo
Your Medical History
Have you experiences any of these health conditions in the past or present?

Hormone ImbalanceCancer/ Systemic diseaseHigh Blood PressureDiabetesHeart problemAuto-immune DisorderEpliepsy/SeizuresCold soresHIV/AIDSLupusHeadaches/ MigranesNoneOther
Acknowledgement and Waiver

I hereby agree to have this treatment be performed on me. I acknowledge that the estheticians may use products that contain these ingredients or are manufactured in a plant with these ingredients. I am aware that even with natural ingredients there is a remote chance of an allergic reaction and there is a possibility of an adverse reaction to product used in facials.

I am also aware that certain services should not be performed with certain medical conditions. I have disclosed all my known medical conditions, allergies, medications and answered all questions honestly on the above form and agree to update Aloha Wax and Lash.

I acknowledge that the estheticians do not provide medical advice and I accept full responsibility to seek out such advice before receiving any services or products from Aloha Wax and Lash. I hereby release, discharge and waive any and all claims against Aloha Wax and Lash performing services or applying any products at Aloha Wax and Lash including from liability and responsibility for any and all illness, injuries, damages, claims, rights and causes of action of any kind or nature, that may occur during or arising out of any services or products received on this and any future dates. I expressly assume and accept the risk for any injuries sustained. I have read this entire document and agree to its terms.
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Your Medical History