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Facial Consultation Form

Birthday
Month
Day
Year
Does your job require you to work outside?
Yes
No
Service scheduled for:
Have you ever had a facial treatment before?
Yes
No
Check each body spa treatment you have had before:
Which of the following best describes your skin type? (Choose one)
Creamy complexion (Always burns easily, never tans)
Light complexion (Always burns, tans slightly)
Light/Matte complexion (Burns moderately, tans gradually)
Matte complexion (Seldom burns, always tans well)
Brown complexion (Rarely burns, deep tan)
Black complexion (Never burns, deeply pigmented)
Have you ever had chemical peels, laser or microdermabrasion?
Yes
No
If yes, was the service within the last month?
Yes
No
Do you use Retin-A, Renová, Adapalene Hydroxyl Acid or Retinol/Vitamin A derivative products
Yes
No
Have you used one of these products in the last 3 months?
Yes
No
Have you used acne medication?
Yes
No

Please include brand, strength and frequency of product used (ex: Neutrogena Hydro face wash twice a day, Sephora hydrating sheet mask once a week, etc)

Have you used any self-tanning lotions, creams or treatments in the last week?
Yes
No
Have you had any recent tanning bed or sun exposure that changed the color of your skin?
Yes
No
Have you used any of the following hair removal methods in the past six weeks?
What areas of concern do you have regarding your SKIN? (Check all that apply)
What areas of concern do you have regarding your EYES? (Check all that apply)
What areas of concern do you have regarding your LIPS? (Check all that apply)
Have you had an allergic to any of the following? (Check all that apply)

Please include the item, your reaction and last occurrence of allergic reaction.

Write ‘None’ if you do not use.

Write ‘None’ if you do not use.

Have you experienced Botox, Restylane, Collagen or other facial injections or fillers?
Yes
No
Are you taking oral contraceptives?
Yes
No
Are you pregnant or trying to become pregnant?
Yes
No
Are you lactating?
Yes
No
What is your current facial hair removal system?
Wet shave
Electric
None
Other
Do you experience any irritation from shaving? (Select all that apply)
May I contact you by text message to confirm future appointments?
Yes
No
May we contact you via email about future promotions, specials and news?
Yes
No

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersede any previous verbal, electronic or written disclosures. I understand what withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release Winx & Wax and its skin care professionals from liability and assume full responsibility thereof.


By selecting “I agree and understand”, I am signing this document electronically. I agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this document. By selecting “I agree and understand” using any device, means, or action, I affirm the accuracy of the information I completed in this document. I further agree that my signature on this document is as valid as if I signed the document in writing.

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