Waxing Intake Form - Skin in the Game DC

Personal Information

Are you taking any medications or steroids? If yes, please list.

Have you had any facial surgery within the past 6 months? If yes, please list

Do you currently have a cold sore?

Yes

No

Have you had a facial before?

Yes

No

Are you currently using any Vitamin A products or been on Acutane within the past 6 months?

Yes

No

What are you goals for this treatment session?

Would you prefer a quiet and serene experience or are would you like to discuss anything in particular?

By signing below, I agree that all the information above is true and I agree to use electronic records and signatures.

Signature