New Waxing Client Intake

Name

First NameLast Name

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Date

Have you ever had a professional waxing?

YesNo

Have you ever had an adverse reaction to waxing? If yes, please explain in "other" section:

YesNoOther

Are you currently affected by any of the following conditions?

Have you been tanning in the past 48 hours?

YesNo

Do you have any medical conditions, health problems, or other physical conditions that might affect your waxing service today? If yes, please explain in "other" section:

YesNoOther

Are you currently taking any of the following medications? Please list any other medications in "other" section:

Have you recently taken any blood thinners (i.e. aspirin, alcohol, Tylenol, etc)? If yes, please list in "other" section:

YesNoOther

It is my choice to receive waxing. I understand that the information given above is strictly confidential and will be used for no other purpose than to assist the service provider customizing my waxing experience. I also understand that failure on my part to disclose information could result in injury and/or illness, and I hereby release Celebrity Skin Chicago from any claims resulting from such. Any information provided to me by the service provider is for general educational purposes only and is not intended for any medical or therapeutic purpose.

My signature below indicates that I have stated any medications that I am taking. I understand it is my responsibility to update the service provider if any of the above information has changed.

Client Signature