WAXING CONSULTATION INTAKE FORM
This form should be completed or reviewed prior to any brow or body waxing service.
Full Name
*
First Name
Last Name
Gender
Please Select
Male
Female
Phone Number
*
Email
*
example@example.com
How did you hear about us?
*
Please Select
Instagram
Facebook
Yelp
Google
Referral
If you were referred by a client, please provide first and last name:
First Name
Last Name
Have you ever had an adverse reaction to waxing?
*
Yes
No
Do you have any tendencies of: Please select all that apply.
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Ingrown Hair
Hyperpigmentation
Scarring
Bruising
Bumps
Burning
Skin Lifting
Boils
None
If yes, explain & indicate which area of the body was affected & when.
Are you currently using or taking: Please select all that apply.
*
Accutane
Retina-A, Renova or Accutane (an oral form of Retin-A)
Other skin-thinning products and/or drugs
Resorcinol
Alpha Hydroxy Acid (AHA) or glycolic acid products in the past 72 hours
Scrub or peel of any kind
Antibiotics
None
Are you seeing a dermatologist for any reason?
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Yes
No
If yes, please explain:
Are you diabetic?
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Yes
No
Do you have any infectious diseases or skin disorders (herpes virus, MRSA, psoriasis, etc.)?
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Yes
No
Do you sun tan or use a tanning bed?
*
Yes
No
Are you currently pregnant?
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Yes
No
What products do you use on your skin? Include brand names.
*
Any known allergies? (Foods, Bees, etc.) List below:
*
When is your menstrual cycle due? For your own personal comfort, you should avoid hair removal two days before/after your cycle. However, we can perform intimate waxing services during this time if a tampon is used. Please put N/A if you’re not receiving a Brazilian service.
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BIKINI/ BRAZILIAN WAXING SERVICES Please practice the same personal hygiene you would for an OB/GYN appointment. Having clean skin, wearing clean undergarments and clothing is recommended. Wax adheres best to clean skin and hair that is free of dirt/debris. Please use the intimate wipe that is provided for use before your appointment. This service also requires some specific positioning on your part and possible participation to hold the skin tight. Both make for a more comfortable service and easier access to all hair being removed. Don't stress, your Esthetician will guide you through this!
*
I understand that proper hygiene is required for these services.
I understand that if I am menstruating, a tampon or cup must be in place.
I understand that my Esthetician has the right to refuse service if proper hygiene is not followed and I am subject to any cancellation penalties.
I agree to follow any pre and post wax care instructions.
I certify that I am 18 years or older and will adhere to the proper hygiene protocol.
I am not receiving a Brazilian wax service.
Do you have at least 3 weeks of hair growth? Hair length should be as long as a grain of rice for best results!
Yes
No
AGREEMENT
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I understand that waxing may cause swelling, tenderness, bruising, scabs, scarring, redness, hyperpigmentation, skin lifting/removal, pimples or other irritation.
I also understand that if I change my skin care routine or medications, I must inform my service provider PRIOR to starting my service in the future.
I confirm that all information given in this form is true, complete, and accurate.
I acknowledge that there are potential risks and complications to receiving any treatment, and I take responsibility for any side effects should they occur. KMC.BEAUTY (Kristine Colvin) is relieved of any liability.
I am willing to follow recommendations made by my esthetician for a home care regimen that can minimize or eliminate possible negative reactions. In the event that I may have additional questions or concerns regarding my treatment or suggested home product / post-treatment care, I will consult the esthetician immediately.
I acknowledge that if I choose not to continue my service for any reason once it has begun, I am subject to the cancellation fee of 100% of the service.
I am over the age of 18 and I consent or have obtained parental consent (signature required) to receive waxing, tinting or intimate body treatments with the understanding that it is an elective procedure, no medical claims are expressed, and no results are guaranteed.
PHOTO RELEASE: I grant permission to KMC.BEAUTY to use my before and after photos which may be used for marketing purposes on a website, social media platform or for a class.
*
Yes
No
Client Signature
*
Today's Date
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-
Month
-
Day
Year
Date
Submit
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