Pre-Appointment Intake Form — Studio Seventeen

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Form Received

Thank you. Your information has been sent to Studio Seventeen and will be reviewed before your appointment.

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Your Information

Full Name *

Phone Number *

Email Address

Appointment Date

Health & Skin History

Please check all that apply *

Diabetes Hormonal Imbalances / PCOS Pregnancy or Breastfeeding Skin Sensitivity Recent Illness or Surgery Varicose Veins (in waxed area) Autoimmune Condition None of the above

Medications & Treatments

Are you currently using, or have you used any of the following in the last 6 months? *

Current Skin Conditions

Do you currently have, or have you recently had: *

Additional Information

If under the age of 18 Parent or legal guardian must sign their full name and date below, and must be present in the treatment room during the service.

Questions prior to your service? Please allow 24–48 hours for a response via text.

How Did You Find Us?

How did you hear about Studio Seventeen?

If you were referred, who referred you?

Photo & Video Release

Are you okay with photos or videos being taken for educational or promotional use? Your choice will not affect your service in any way.

Terms & Conditions

I confirm that the information provided above is accurate and complete. I understand that any concerns or conditions must be discussed with my service provider prior to service. I acknowledge that waxing services may not be appropriate for all skin types and conditions, and I release Studio Seventeen from liability for any reactions resulting from undisclosed health information.

I have read and agree to the terms above *

Signature or initials *