Spa - Waxing & Nails Consultation Form

Your Information

Last Name *

First Name *

Room

Arrival

Departure
COVID-19 Health Check

Are you suffering any flu like symptoms

Are you suffering any flu like symptoms: yes no

Are you experiencing any difficulty in breathing, shortness of breath

Are you experiencing any difficulty in breathing, shortness of breath: yes no

Are you experiencing any fever/temperature symptoms

Are you experiencing any fever/temperature symptoms: yes no

If so, did you consult a Doctor or other medical practitioner

If so, did you consult a Doctor or other medical practitioner: yes no

How are you feeling health wise

How are you feeling health wise: well unwell

Have you been in contact with someone confirmed to have COVID-19 within the last 14 days

Have you been in contact with someone confirmed to have COVID-19 within the last 14 days: yes no

NOTE COVID-19 HEALTH CHECK

NOTE: When in the Spa & Salon facilities, please adhere to our standard processes and procedures regarding physical distancing, infection control, i.e., hand washing/hand sanitizing and general coughing/sneezing etiquette.
General Health Check

Please carefully read the following list

Please carefully read the following list of conditions and questions below and check any that have affected your health either recently or in the past. For present conditions we recommend you proceed only with doctor’s approval.

Diabetes
Diabetes

Sinus Infection
Sinus Infection

Skin Rashes/Conditions
Skin Rashes/Conditions

Blood Clots/Poor Circulation
Blood Clots/Poor Circulation

Back Pain
Back Pain

Contagious Conditions
Contagious Conditions

Muscle or Joint Pain/Cramps
Muscle or Joint Pain/Cramps

Tension Headaches / Migraines
Tension Headaches / Migraines

Asthma
Asthma

Nut Allergy
Nut Allergy

High or Low Blood Pressure
High or Low Blood Pressure

Other
Other

Fluid Retention
Fluid Retention

Epilepsy or Seizures
Epilepsy or Seizures

Heart Condition / Pacemaker
Heart Condition / Pacemaker

Other General health specify

Is there anything else you we should know regarding your health which may affect or prevent you from having a treatment

Is there anything else you we should know regarding your health which may affect or prevent you from having a treatment: yes no

is there anything... - If Yes, please specify

Do you have sensitivity to heat, aromatherapy, or fragrances

Do you have sensitivity to heat, aromatherapy, or fragrances: yes no

Do you have sensitivity - If Yes, please specify
Nail Services Consultation

Is this your first Manicure or Pedicure

Is this your first Manicure or Pedicure: yes no

Have you ever had an allergic reaction to any type of nail product

Have you ever had an allergic reaction to any type of nail product: yes no

If Yes, please explain

Do you bleed easily around the cuticles or nailbed

Do you bleed easily around the cuticles or nailbed: yes no

How would you describe the typical condition of your nails 2

How would you describe the typical condition of your nails

Soft & Brittle
Soft & Brittle

Snap Easily
Snap Easily

Normal
Normal

Peeling
Peeling

Bendy
Bendy

Flaky
Flaky

Hard
Hard

Split Easily
Split Easily
Waxing Consent

I have been informed that it is not advisable to have this treatment if I am using any prescription skin care or medications that can cause thinning of the skin. I have been told that I cannot wax if I am using or have used in the past six months: Retin A, Vitamin A Acid, All-trans Retinoic Acid, Retinoic Acid Tretinoin or have used Accutane (systemic Retinoid), Differin or sun sensitive medications.

I have been informed that it is not advisable to have this treatment if I am using any prescription skin care or medications that can cause thinning of the skin. I have been told that I cannot wax if I am using or have used in the past six months: Retin A, Vitamin A Acid, All-trans Retinoic Acid, Retinoic Acid Tretinoin or have used Accutane (systemic Retinoid), Differin or sun sensitive medications.

I agree with the above

I agree with the above: yes no

I understand that sun exposure after waxing can cause irritation, pigmentation and burn

I understand that sun exposure after waxing can cause irritation, pigmentation and burn: yes no

Total sun-block has been advised to prevent pigmentation that can result from waxing

Total sun-block has been advised to prevent pigmentation that can result from waxing: yes no

I am aware that redness and bumps may occur after waxing and I may experience some discomfort. Bikini and Brazilian waxing during feminine cycle is not recommended

I am aware that redness and bumps may occur after waxing and I may experience some discomfort. Bikini and Brazilian waxing during feminine cycle is not recommended: yes no

I have reviewed this form and understand that this information will be used for the sole purpose of my treatment and any further treatments at The Jumby Spa only.

Yes, I give permission to store and process my data

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