Waxing Consultation Form

Date

Name

First NameLast Name

Email

example@example.com

Phone Number

Area CodePhone Number

Age*

Have you used any Alpha Hydroxy Acids (AHA), chemical peels or glycolic products in the past 5-7 days?*

YesNo

Have you been prescribed or had any of the following in the past year?*

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

YesNo

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

YesNo

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

current conditions/ illnesses

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

medications

Do you have any open skin lesions?

YesNo

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

allergies

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 service provider. I give permission to perform the waxing procedure we have discussed and will hold 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 48 hours after waxing; and all home skin care protocols as recommended by my service provider. I understand that my service provider will take every precaution to minimize or eliminate negative reactions as much as possible.

Signature*

Waxing Form