Does your job require you to work outside?*
Have you ever had a facial treatment before?*
Check each body spa treatment you have had before:*
Which of the following best describes your skin type? (Choose one)*
Have you ever had chemical peels, laser or microdermabrasion?*
If yes, was the service within the last month?
Do you use Retin-A, Renová, Adapalene Hydroxyl Acid or Retinol/Vitamin A derivative products*
Have you used one of these products in the last 3 months?*
Have you used acne medication?*
Have you used any self-tanning lotions, creams or treatments in the last week?*
Have you had any recent tanning bed or sun exposure that changed the color of your skin?*
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)*
Have you experienced Botox, Restylane, Collagen or other facial injections or fillers?*
Are you taking oral contraceptives?*
Are you pregnant or trying to become pregnant?*
What is your current facial hair removal system?
Do you experience any irritation from shaving? (Select all that apply)*
May I contact you by text message to confirm future appointments?*
May we contact you via email about future promotions, specials and news?*
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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