City:  State  Zip Code 




Cell Phone: 

Known Allergies: 


Please let us know if you are experiencing any of the following. Check all that may apply:


Are you under care of a Dermatologist? 

Please describe your specific skin concern:

What are the end results that you are expecting to accomplish?

Wax Treatment Information 

Have you used Accutane for the past 6 months?

Have you used the following products within the past week?





Massage Therapy

Have you ever experienced an allergic reaction to products?

Are you pregnant?  

Do you have poor circulation? 


Have you ever received professional massage/body  work before? 

What type of massage/bodywork do you prefer?

What are your goals/expected outcomes for receiving massage/bodywork?

Please make us aware of any of the following conditions by checking all that apply:


Personal Preferences

How did you hear about Magnolia?

Referral’s name: 

 which paper or article? 
please specify

Please let us know what brings you into City Magnolia today:

please specify

Would you like to receive City Magnolia specials? (check all that apply)

How would you like to receive a confirmation?

Treatment Policies:

I, , understand fully and agree to comply with all of the treatment policies listed below. I understand that these guidelines are set for health reasons and that they are made on behalf of myself and others.

  1. We do not wax any individuals who are on any medication that thins or exfoliates the skin, including Accutane or Retin-A, or anyone receiving radiation treatments or chemotherapy.
  2. We are unable to treat clients with questionable medical conditions such as Herpes Simplex (cold sores, fever blisters, open wounds, sores healing incisions, infectious diseases, etc).
  3. Cancelation policy: We require at least 24 hours advance notice for cancelation of weekday (Tuesday, Wednesday, or Thursday) single services, and at least 48 hours advance notice for cancelation of multiple services booked on the same day, groups of more than 2, spa packages, or Friday/Saturday/Sunday services. Failure to cancel your appointment before the allotted time will result in 25% of the service price charged.
  4. All information received by the client on the form is completely private and confidential.

Follow Up Contact:

City Magnolia would like to contact you for feedback about the services you received today. We would also like to send you information about exclusive specials and directions for leaving us outstanding reviews online.


Client’s Signature

Signed and agreed on this .