A Spa to Remember Waxing Form

Address*

Would you like to receive text messages of our weekly specials?*
YesNo

Referred by*

Are you on Instagram? Follow us! @aspatorememberwestford*

Do you have any known allergies?*

Diabetes? *
YesNo

Are you taking any topical medications? *
YesNo

Are you taking any oral medications? *
YesNo

If yes, please list:*

Are you under a Doctor’s care for any skin conditions?*
YesNo

If yes, please list:*

Are you presently using or have you used any of the following products in the past two weeks?
Check all that apply.
Glycolic AcidAlfra HydroxyTazaroteneErythromycinRetin ARenovaTretinoinDoxycyclineAccutaneAdapaleneMinocylineTetracyclineNoneOther

Have you ever experienced an adverse reaction to a waxing treatment?*
YesNo

If yes, please explain:

By entering your name, date and signature below, you are effectively providing your signature,
indicating that all the information on this form is true and accurate, to the best of your knowledge.