MaliaSkinLLC Waxing Treatment Intake Form
Please complete this form before your waxing appointment to ensure a safe and comfortable experience.
Personal Information
Tell us about yourself.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact and phone
*
Have you had waxing treatments before?
*
Yes
No
Which areas would you like to have waxed?
*
Brazilian
Bikini line
Upper Lip
Chin
Arms
Legs
Back
Underarms
Other
Do you have any allergies? (e.g., latex, adhesives, fragrances)
*
Yes
No
If yes, please list your allergies.
*
Are you currently taking any medications that may affect your skin? (e.g., Accutane, Retin-A, antibiotics)
*
Yes
No
If yes, please list the medications.
*
Do you have any of the following skin conditions?
*
Sensitive Skin
Eczema
Psoriasis
Rosacea
Sunburn
None
Is there anything else we should know about your health or skin?
*
Signature
Submit Intake Form
Submit Intake Form
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