Wax Intake Form

Wax Intake Form
- Name*
  
  First NameLast Name
- Phone Number*
  Please enter a valid phone number.
- Email*
  example@example.com
- Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Birthday *
  
  MonthDayYear
  Date
- How did you find Kempt Esthetics?*
  Where you referred by anyone? If so, who?
- YESNO
- Have you been waxed before?*
- Please list any allergies or sensitivities:*
- YESNO
- YESNO
- YESNO
- YESNO
- YESNO
- ECZEMA/PSORIASISHEPATITISAIDS/HIVCOLD SORES/FEVER BLISTERSHERPESNONE OF THE ABOVE
- IF YOU ARE USING ANY OF THE FOLLOWING MEDICATIONS, YOU CAN NOT BE WAXED TODAY*:
  
  - ACCUTANE
  
  - RENOVA
  
  - TRETINOIN
  
  - ADAPALENE
  
  - ALUSTRA
  
  - AVAGE
  
  - ISOTERETINOIN
  
  - RETIN-A
  
  - AVITA
  
  - TAZAROTENE
  
  *at time of scheduled appointment
  
  If you have any questions, please Contact Kempt Esthetics.
- YES, I ACCEPT RESPONSIBILITY
- I understand, acknowledge and agree that I have provided all relevant information regarding my medical history and health conditions. I agree that the esthetician is not responsible for any doctor co-pays or bills that may occur after the procedure. I am over the age of 18 years old. I have come to this location at my own free will. I understand this consent agreement is legal and binding and I will hold Kyana Bailey and Kempt Esthetics harmless from any liability that may result from this treatment. By signing below, I agree to the terms listed above.
  
  Clear
- Should be Empty: