Name

First Name

Last Name

Phone

(###)

###

####

Birthday

YYYY

Referred By

Service you are inquiring about:

SKIN + WAX

Occupation

Does your employer require you to work outdoors?

Yes

What would you like to achieve from your treatment today?

Which of the following describes your skin type?

Type I Very Fair- Always burns easily, never tans

Type II Fair- Always burns, tans slightly

Type III Medium-Burns moderately, tans gradually

Type IV Olive- Seldom burns, always tans well

Type V Brown/Dark Brown- Rarely burns, deep tan

Type V Black- Never burns, deeply pigmented

Do you have any special skin problems or concerns pertaining to your face or body?

Have you ever had chemical peels, laser, or microdermabrasion?

Yes

In the last month?

Yes

Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/ Vitamin A derivative products?

Yes

Have you used any of these products in the last 3 months?

Yes

If yes, which product?

Have you used an acne medication?

Yes

If yes, which medication?

Have you experienced Botox, Restylane or Collagen injections?

Yes

How long ago?

What SPF do you use on your face? How often/when?

What SPF do you use on your body? How often/when?

Have you had any recent tanning bed or sun exposure that changed the color or your skin?

Yes

What is your current skincare routine? What products are you currently using? (List brands where known)

Have you used any of the following hair removal methods in the past six weeks?

Shaving

Waxing

Electrolysis

Plucking

Tweezing

Stringing

Depilatories

FEMALE CLIENTS ONLY

Are you taking oral contraceptives?

Yes

Have you had any recent changes to or from your contraceptive treatment?

Are you pregnant or trying to become pregnant?

Yes

Are you currently breastfeeding?

Yes

Are you experiencing any menopause symptoms?

Are you undergoing hormone replacement therapy?

MALE CLIENTS ONLY

What is your current shaving system?

Wet Shave

Electric

Do you experience irritation from shaving?

Yes

Do you ever get ingrown hairs?

Yes

EYELASH LIFT

Is this the first time you have had your eyelashes lifted?

Yes

Do you habitually rub, pull, or pick your eyelashes for any reason?

Yes

Do you have, or are you being treated for any eye illness or injury?

Yes

Are you able to keep your eyes closed and lie still for up to 3 hours or longer?

Yes

Please use this space to complete answers where space was insufficient.

What is your preferred method of contact for future appointment reminders/correspondence?

Phone Call

Text Message

I understand, have read and completed this questionnaire truthfully. I understand that 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 this institution and/or skin care professional from liability and assume full responsibility thereof. By entering your initials in the box 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. Please type your name indicating that you have read and agree to the terms above.

Cancellation Policy: We ask that you call or email us at least twenty-four (24) hours in advance if you need to cancel your appointment. We will attempt to confirm cancellation as soon as we receive the message and respond for rescheduling. If we are unable to contact you or you have not received cancellation confirmation, we highly advise that you follow up with us so as not to be inadvertently placed on our NO CALL / NO SHOW list. If you fail to cancel your appointment within twenty-four (24) hours, you will be charged, at minimum, fifty percent (50% ) of your service or more depending on time allotted for your services. If you NO CALL / NO SHOW, you will be expected to pay full price for services missed before scheduling your next appointment. Since we do not schedule multiple clients within the same hour, last minute cancellations and late arrivals impose a great inconvenience and loss to the salon. If you are more than ten (10) minutes late without contacting us, your appointment may be rescheduled. We firmly believe in the value of your time and make a conscious effort to avoid long waiting periods in the salon. We understand that at times it may be difficult to find an appointment that fits both yours and our schedules and that running late can put both of those schedules behind. Please advise us, when scheduling your appointment, of any potential conflicts that may affect your appointment time. This would include any appointments on your schedule immediately following your service, so that we can make sure you can get there on time. First Time Clients: If in the event you do not show up for your first appointment we will no longer allow you to schedule appointments at J3. As a courtesy, we send out invites via email. Please remember to accept the invite and put it in your calendar, if available. We will call to remind you of your appointment the business day before your appointment. However, if we are unable to call or reach you, please understand that it is your responsibility to remember your appointment dates and times to avoid late arrivals, missed appointments and the cancellation fee. Please type your name indicating that you have read and agree to the terms above.

Thank you for choosing J3-Studio!