Waxing Intake Form

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Area CodePhone Number

Date of Birth*

Have you used any Alpha Hydroxy Acids (AHA) or glycolic products in the past 3 days?*

Have you used Retin-A, Tretinoin, or Accutane within the past year? If so, when?*

Do you use tanning beds and/or are exposed to the sun on a regular basis?

Are you using any other skin-thinning products and/or drugs that thin the blood?*

Are you currently taking any medications? If so, please list.

Please list any illness/conditions which ou are currently being treated for by a medical professional.

Do you have any open skin lesions?

Do you have any allergies? If so, please list.*

I give permission to have images and/or videos taken of me during waxing sessions and used for marketing and social media (public), educational, and portfolio purposes?*

Other

Please note that waxing can have certain side effects such as skin removal, redness, swelling, tenderness, etc.

I have read the above information and have given an accurate account of the questions and if I have any concerns, I will address these with my Esthetician. I give permission to my Esthetician to perform the waxing procedure we have discussed and will hold her harmless from any liability that may result from this treatment. I agree to adhere to all safety post care including: no peels, tanning, or wet room services; no swimming/spas/hot tubs for 72 hours after waxing; and all home skin care protocols as recommended by my service provider. I understand that my Esthetician will take every precaution to minimize or eliminate negative reactions as much as possible.

Signature*

Date?*