The Wax Diva - New Client Information

Client Information

Please fill out the following questions before your appointment. Thanks, and I look forward to seeing you!
Full Name*

First NameLast Name
E-mail*
Birth Date

MonthDayYear
Phone Number*

Area CodePhone Number
This is my...*

Home phoneMobile phone
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Are you using any of the following medictation or skin products?

Retin-aRenovaAccutaneAHA or Glycolic products (w/in past 48-72 hours)
Have you been tanning within the past 48 hrs?
Known allergies
Please list your allergies here:
How did you find out about The Wax Diva?*

Facebook/YelpInternetReferral/Friend
If referred by someone, please let us know who:
I have waxed the following:

EyebrowsArmpitsUpper LipNose/EarArms/LegsBackBrazilianFeet
I like to wax...
Sign here to confirm

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Thank you for completing this client information form. By giving The Wax Diva your contact information you will be subscribed to a monthly newsletter for all clients. Your information will never be shared with anyone else besides The Wax Diva and you can unsubscribe at any time...but be forewarned -you will miss out on things like birthday specials and monthly deals xoxo Tamara
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