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Health Therapy & Beauty Center

Ft Myers Massage and Skincare Center

(239) 900-300512791 Kenwood Lane #1001, Fort Myers

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Facials
Waxing
- Brazilian Wax
- Hair Removal – Waxing
Massages
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Buy Gift Cards
Facials
Waxing
- Brazilian Wax
- Hair Removal – Waxing
Massages
Read Our Reviews

Waxing Services Intake Form

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Waxing Services Intake Form

Save time when you arrive to our spa by completing our massage intake form before you arrive. You may also be directed to this form upon arrival if you prefer an electronic version.

Service Requested (check all that apply) *

Face
Brow
Lip
Chin
Full Face
Sideburns
Full Arms
Half Arms
Underarms
Back/Shoulder
Abdomen
Chest
Full Legs
Half Legs
Brazilian
Bikini
Full Body
Other

Name *

First

Last

Phone *

Date of Birth *

Address *

Address Line 1

City

State

Zip Code

Occupation

How did you hear about us?

May we contact you about upcoming promotions/discounts? *

Yes
No

Do you prefer to be contacted by: *

Text
Email

Email Address

Texting Number

Do you have any tendencies to (check all that apply):

Ingrown Hair
Scarring
Bumps
Bruising
Hyperpigmentation

of tendencies on

Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 72 hours? *

Yes
No

Are you using Retin-A, Renova, or Accutane? *

Yes
No

Are you using any other skin thinning products and/or drugs? *

Yes
No

Are you exposed to the sun on a daily basis? *

Yes
No

Do you plan to spend more time in the sun soon? *

Yes
No

Do you use a tanning bed? *

Yes
No

Have you ever had a waxing treatment before? *

Yes
No

Have you ever had a reaction to waxing? *

Yes
No

What skin products do you regularly use on your skin?

Do you approve us taking pictures during your service that we may use on our website or social media? *

I approve
I do not approve

Signature *

Clear Signature

Date *

Contact Info

Location:
12791 Kenwood Lane #1001
Ft Myers, FL 33907
Phone:
(239) 900-3005
Business Hours:
BY APPOINTMENT ONLY
Mon - Friday: 8 AM - 6 PM
Sat: 8 AM - 12 PM
Sun: Closed

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Intake Forms

FB 9764846 / MA 94290 / MM 43440

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