Wax Questionnaire & Consent

Wax Questionnaire & Consent

The questions and information below are to provide you with a safe and effective waxing experience, home care recommendations, and superior customer service. Your information is confidential and is never shared with an outside source.
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email *
example@example.com
Phone Number *
Please enter a valid phone number.
Birthday *

Month Day Year
Date
Best way to contact you? Note: Appointment reminders are sent via email and text.

Call me Text me Email me
Emergency contact:
Enter name and phone number
How did you hear about us?

Internet search Social Media Yelp Friend
If referred by a friend, please list their name so we may thank them.
Would you like to be on our email list? You'll stay current on skin health, special VIP offers, and (when available) last-minute openings.

Yes No, thanks I'm already signed up, keep 'em coming!
Which body part(s) are we waxing at this appointment?
Have you been waxed before?

Yes No
If yes, how long ago was your last wax?
When did you last shave or trim?

Do you have a tendency towards: *

	Yes	No
Breakouts in waxing area
Bruising
Bumps when waxing (histamine response)
Eczema
Hyperpigmentation (dark spots)
Ingrown hairs
Psoriasis
Scarring

If yes to any of the above, please describe your experience.

Are you currently taking, using or participating in any of the following: *

	Yes	No
Accutane / Isotrentinoin
Alpha-hydroxy acid and/or Beta-hydroxy acid (AHA & BHA)
Glycolic Acid
Indoor tanning (tanning bed)
Resorcinol
Retin-A
Scrubs or peels
Self tanners

If yes to any of the above, please describe and include the date or approximately how long ago you took, used or participated in the item.

Do you currently have or have had: *

	Yes	No
Allergies
Cold sores / herpes virus (active or dormant)
Staph / MRSA (active or dormant)

If yes to any of the above, please describe

Acknowledgement and Consent: Please check the boxes to acknowledge that you have read the information and consent to the statement. Submitting this form implies the agreement/consent of receiving services from Skin Care by Alison. *

	I agree / understand
WAXING MAY CAUSE: Bruises, scabs, scarring, redness, hyperpigmentation, pimples or a flare up of any of the above mentioned conditions/responses. Waxing of soft tissue may cause the skin to tear resulting in the need for stitches (most commonly in Brazilian and bikini area waxes in both males and females).
I understand that if I am applying Retin A (any Vitamin A derivative) anywhere on my body that it gets absorbed into my bloodstream and it doesn’t matter where it is applied, all my skin is affected. Use of Retin A, et al, can cause my skin to lift, split or bleed.
I understand that if I have herpes, staph/MRSA, I may experience an outbreak after the waxing service. The professional has explained the best way to minimize or prevent an outbreak when waxing regularly.
I understand I may carry herpes and/or staph/MRSA without any physical symptoms or a medical diagnosis. I also understand that the waxing service does not allow the opportunity to contract these conditions from my technician or the products and tools used.
I understand that if I have an active herpes and/or staph/MRSA outbreak near or at the area being waxed I will need to reschedule my appointment.
I understand all of the above mentioned reactions are possibilities. I also understand if I change my skin care routine or medications I must inform Skin Care by Alison PRIOR to any service in the future.
I understand that I must be clean and prepared for my service.
I understand that if I cancel with less than 24-hours notice or am a no-show I will be charged the full cost of my scheduled service(s). If I have not placed a credit card on file, I acknowledge I will receive an electronic invoice and will provide payment within five (5) days of issuance.
I certify the information I provided is true and correct and I agree to receive services from Skin Care by Alison and I understand the possible risks it entails.
I accept full responsibility of the use of Skin Care by Alison at my own risk & do not hold Skin Care by Alison, Alison Phillips et al liable for loss, damage or injury.

Signature *

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