Waxing Intake Form

Waxing Intake Form

Luxe Skin Studio
Client Information
Client Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*

Area CodePhone Number
Date of Birth*

MonthDayYear
Date
Occupation*
How did you hear about us?*
Medical / History Data
Have you taken Accutane in the past year?*

YesNo
Are you currently using Retin-A, Renova or Differin?*

YesNo
Are you currently sunburnt?*

YesNo
Are you diabetic?*

YesNo
Do you frequently use tanning beds?*

YesNo
Do you currently have or have you had any of the following medical conditions that could compromise your service?

HIV/AIDSCancerHepatitisHerpesCold Sores/Fever BlistersVaricose VeinsEczema/Psoriasis
Read Carefully. If you are currently using any of the following medications, you cannot be waxed at your appointment.
- Accutane
- Renova
- Tretinoin
- Avita
- Differin
- Isotretinoin
- Retin-A
- Tazarotene
- Alustra
- Adapalene
Authorization
I have completed this form to the best of my ability and knowledge and agree to inform the esthetician of any changes in the above information. I understand that withholding information or providing misinformation may result in contraindications or irritation to the skin from treatment received. The treatments I receive here at Luxe Skin Studio are voluntary and I release this skin care professional from liability and assume full responsibility thereof. I accept full responsibility for any adverse reactions. I understand that waxing may cause some redness, bumps and/or itching.
Client Signature*

Clear
If under 18, Parent/Guardian Name

First NameLast Name
Parent/Guardian Signature

Clear
Should be Empty:

Waxing Intake Form

Client Information

Medical / History Data

Authorization